Molina Healthcare of Wisconsin, Inc. health insurance plan with the Plan ID 52697WI0010002. The plan is called Constant Care Silver 1.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.34% (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 28.66% 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 | 52697WI0010002 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Wisconsin | ||||||||||||||||||
Health Insurance Issuer | Molina Healthcare of Wisconsin, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 52697WI0010002-00 | ||||||||||||||||||
Provider Network(s) | ['WIN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 52697WI0010002-00 Standard On Exchange Plan - 52697WI0010002-01 Open to Indians below 300% FPL - 52697WI0010002-02 Open to Indians above 300% FPL - 52697WI0010002-03 73% AV Silver Plan - 52697WI0010002-04 |
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Last Plan Update Date | Fri, 02 Dec 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
NO | ||
Autism Spectrum Disorders - Intenstive Level Services
|
YES | $30.00 |
100.00% |
Autism Spectrum Disorders - Non-Intensive Level Services
|
YES | $30.00 |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year |
YES | $60.00 |
100.00% |
Chemotherapy
Intravenous chemotherapy is covered. |
YES | 50.00% |
100.00% |
Chiropractic Care
|
YES | $60.00 |
100.00% |
Clinical Trials
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Separate cost-sharing may apply for professional services. Maximum two days of facility copayments per inpatient admission. |
YES | $1,200.00 |
100.00% |
Dental Anesthesia
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Care Management
|
YES | No Charge |
100.00% |
Diabetes Education
|
YES | No Charge |
100.00% |
Dialysis
|
YES | $60.00 |
100.00% |
Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | $950.00 |
$950.00 |
Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information |
YES | $29.00 |
100.00% |
Habilitation Services
|
YES | $60.00 |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 3 Years Limited to one hearing aid per ear every three years |
YES | 50.00% Coinsurance after deductible |
100.00% |
Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | No Charge |
100.00% |
Hospice Services
|
YES | No Charge |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1200.00 Copay per Day |
100.00% |
Inpatient Physician and Surgical Services
|
YES | $60.00 |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | $60.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
|
YES | $1200.00 Copay per Day |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $30.00 |
100.00% |
Mental Health Other
|
YES | $30.00 |
100.00% |
Newborn Services Other
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Non-Preferred Brand Drugs
Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information |
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
NO | ||
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Ostomy Supplies
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year 20 visits/yr for each service (Physical Therapy, Occupational Therapy, Speech Therapy, and Pulmonary Rehabilitation Therapy) |
YES | $60.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Post-cochlear implant aural therapy
Limit: 30.0 Visit(s) per Year |
YES | $60.00 |
100.00% |
Preferred Brand Drugs
Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information |
YES | $60.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
Prescription Drugs Other
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
Limit: 1.0 Item(s) per 3 Years |
YES | 50.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | $60.00 |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year 20 visits per year limit for occupational therapy and 20 visits per year limit for physical therapy |
YES | $60.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | $60.00 |
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: 30.0 Days per Year |
YES | $1200.00 Copay per Day |
100.00% |
Specialist Visit
|
YES | $60.00 |
100.00% |
Specialty Drugs
Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to www.molinahealthcare.com for formulary information |
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | $1200.00 Copay per Day |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
Transplant
|
YES | $60.00 |
100.00% |
Treatment for Temporomandibular Joint Disorders
Limit: 1.0 Procedure(s) per Year 1 surgical procedure and 3 visits per year |
YES | 50.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $30.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | $95.00 |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.713354069 |
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 |
Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $5000 per group |
Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $2500 per person |
Drug EHB Deductible, Combined In/Out of Network, Individual | $2,500 |
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Drug EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Drug EHB Deductible, Out of Network, Family Per Person | 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, Depression, Diabetes, High Blood Pressure & High Cholesterol |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | WIF002 |
Formulary URL | URL |
HIOS Product ID | 52697WI001 |
Import Date | 12/2/2022 1:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 2 |
HSA Eligible | No |
New/Existing Plan | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer ID | 52697 |
Issuer Marketplace Marketing Name | Molina Healthcare |
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 | $5000 per group |
Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $2500 per person |
Medical EHB Deductible, Combined In/Out of Network, Individual | $2,500 |
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $2,500 |
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 | WIN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | No |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 52697WI0010002-00 |
Plan Marketing Name | Constant Care Silver 1 |
Plan Type | HMO |
Plan Variant Marketing Name | Constant Care Silver 1 250 Off Exchange |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $2,100 |
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 | $1,400 |
SBC Scenario, Having Diabetes, Deductible | $800 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $900 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,200 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | WIS001 |
Source Name | HIOS |
Plan ID | 52697WI0010002 |
State Code | WI |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $9,100 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18200 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
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 | Yes |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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