Silver 12 with First 4 Primary Care Visits Free
Silver 12 with First 4 Primary Care Visits Free is a Silver HMO plan by Molina Healthcare.
Locations
Silver 12 with First 4 Primary Care Visits Free is offered in the following counties.
Plan Overview
Insurer: | Molina Healthcare |
Network Type: | HMO |
Metal Type: | Silver |
HSA Eligible?: | No |
Plan ID: | 54172FL0010011 |
Cost-Sharing Overview
Silver 12 with First 4 Primary Care Visits Free offers the following cost-sharing.
Cost-sharing for Silver 12 with First 4 Primary Care Visits Free includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Pocket Maximum: | $9200 per person | $18400 per group |
Deductible: | $7000 per person | $14000 per group |
Coinsurance: | 20.00% |
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Silver 12 with First 4 Primary Care Visits Free will be shown below if applicable.
Cost Sharing Type | Individual | Family |
---|---|---|
Out-of-Network Maximum: | per person not applicable | per group not applicable |
Out-of-Network Deductible: | per person not applicable | per group not applicable |
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
Deductible: | $7,000 |
Copayment: | $30 |
Coinsurance: | $1,100 |
Limit: | $0 |
Deductible: | $900 |
Copayment: | $1,700 |
Coinsurance: | $0 |
Limit: | $0 |
Deductible: | $2,100 |
Copayment: | $200 |
Coinsurance: | $0 |
Limit: | $0 |
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.
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
Silver 12 with First 4 Primary Care Visits Free offers the following features and referral requirements.
Wellness Program: | Yes |
Disease Program: | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
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 Silver 12 with First 4 Primary Care Visits Free covers when you are out of the service area or out of the country.
Out of Country Coverage: | No |
Out of Country Coverage Description: | |
Out of Service Area Coverage: | No |
Out of Service Area Coverage Description: | |
National Network: | No |
Additional Benefits and Cost-Sharing
Silver 12 with First 4 Primary Care Visits Free includes the following benefits at the cost sharing rates listed below.
Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
---|---|---|---|
Primary Care Visit to Treat an Injury or Illness Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
Specialist Visit Covered | $62.50 Not Applicable | Not Applicable 100.00% | |
Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Hospice Services Covered | Not Applicable No Charge | Not Applicable 100.00% | |
Routine Dental Services (Adult) | |||
Infertility Treatment | |||
Long-Term/Custodial Nursing Home Care | |||
Private-Duty Nursing | |||
Routine Eye Exam (Adult) | |||
Urgent Care Centers or Facilities Covered | $60.00 Not Applicable | Not Applicable 100.00% | |
Home Health Care Services Covered | Not Applicable No Charge | Not Applicable 100.00% | 20.0 Days per Benefit Period |
Emergency Room Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 20.00% Coinsurance after deductible | |
Emergency Transportation/Ambulance Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 20.00% Coinsurance after deductible | |
Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Inpatient Physician and Surgical Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Bariatric Surgery | |||
Cosmetic Surgery | |||
Skilled Nursing Facility Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Days per Benefit Period |
Prenatal and Postnatal Care Covered | No Charge Not Applicable | Not Applicable 100.00% | |
Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Mental/Behavioral Health Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
Mental/Behavioral Health Inpatient Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Substance Abuse Disorder Outpatient Services Covered | $40.00 Not Applicable | Not Applicable 100.00% | Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
Substance Abuse Disorder Inpatient Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Generic Drugs Covered | $5.00 Not Applicable | Not Applicable 100.00% | |
Preferred Brand Drugs Covered | $100.00 Not Applicable | Not Applicable 100.00% | |
Non-Preferred Brand Drugs Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Specialty Drugs Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Outpatient Rehabilitation Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
Habilitation Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
Chiropractic Care Covered | $40.00 Not Applicable | Not Applicable 100.00% | 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
Durable Medical Equipment Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Hearing Aids | |||
Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Preventive Care/Screening/Immunization Covered | No Charge Not Applicable | Not Applicable 100.00% | |
Routine Foot Care Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
Acupuncture | |||
Weight Loss Programs | |||
Routine Eye Exam for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Visit(s) per Year |
Eye Glasses for Children Covered | No Charge Not Applicable | Not Applicable 100.00% | 1.0 Item(s) per Year |
Dental Check-Up for Children Not Covered | |||
Rehabilitative Speech Therapy Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
Well Baby Visits and Care Covered | No Charge Not Applicable | Not Applicable 100.00% | |
Laboratory Outpatient and Professional Services Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
X-rays and Diagnostic Imaging Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Basic Dental Care – Child Not Covered | |||
Orthodontia – Child Not Covered | |||
Major Dental Care – Child Not Covered | |||
Basic Dental Care – Adult | |||
Orthodontia – Adult | |||
Major Dental Care – Adult | |||
Abortion for Which Public Funding is Prohibited | |||
Transplant Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Accidental Dental Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Dialysis Covered | $62.50 Not Applicable | Not Applicable 100.00% | |
Allergy Testing Covered | $40.00 Not Applicable | Not Applicable 100.00% | |
Chemotherapy Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Radiation Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Diabetes Education Covered | No Charge Not Applicable | Not Applicable 100.00% | |
Prosthetic Devices Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Infusion Therapy Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | |
Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | 2.0 Procedure(s) per Year two TMJ procedures per year and one splint per six-month period |
Nutritional Counseling Covered | No Charge Not Applicable | Not Applicable 100.00% | Diabetes coverage includes ‘nutrition counseling’; home health services include ‘nutritional guidance.’ |
Reconstructive Surgery Covered | Not Applicable 20.00% Coinsurance after deductible | Not Applicable 100.00% | Only for Breast reconstruction following a Mastectomy. |
Gender Affirming Care |
Free Preventive Services
There is no copayment or coinsurance for any of the following Silver 12 with First 4 Primary Care Visits Free 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.
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Silver 12 with First 4 Primary Care Visits Free including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
Summary of Benefits: | Summary of Benefits Link |
Plan Brochure: | Plan Brochure Link |
Formulary: | Formulary Link |
Premium Payment Website: | Premium Payment Link |
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