Gold 1800 Ded/5600 MOOP - 94529WI0240049 Health Insurance Plan

Group Health Cooperative of South Central Wisconsin health insurance plan with the Plan ID 94529WI0240049. The plan is called Gold 1800 Ded/5600 MOOP.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.92% (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 18.08% 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 94529WI0240049
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer Group Health Cooperative of South Central Wisconsin
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 94529WI0240049-00
Provider Network(s) ['WIN001']
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 Wisconsin 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 - 94529WI0240049-00

Standard On Exchange Plan - 94529WI0240049-01

Open to Indians below 300% FPL - 94529WI0240049-02

Open to Indians above 300% FPL - 94529WI0240049-03

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Gold 1800 Ded/5600 MOOP Health Insurance Plan, 94529WI0240049-00

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

20.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
NO
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Cardiac Rehabilitation

Limit: 36.0 Visit(s) per Year

YES

20.00% Coinsurance after deductible

100.00%
Chemotherapy

Intravenous chemotherapy is covered.

YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

YES

$25.00

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

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

20.00%

100.00%
Emergency Room Services

Copay waived if admitted as a hospital inpatient.

YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00

100.00%
Gender Affirming Care

Medically Necessary Gender Affirming Care is covered. GHC-SCW does not discriminate on the basis of sexual orientation or gender identity.

YES

20.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

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. PT/OT Habilitative Therapies have a combined limit of 40 Visits per year. Habilitative Speech Therapy and Cognitive Therapy have a limit of 20 Visits per therapy per year.

YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

1 Hearing Aid per ear per 36 months.

YES

20.00%

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$25.00

100.00%
Non-Preferred Brand Drugs
YES

$75.00

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

$25.00

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

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term. PT/OT Rehabilitative Therapies have a combined limit of 40 Visits per year. Rehabilitative Speech Therapy, Pulmonary Rehabilition, and Cognitive Therapy have a limit of 20 Visits per therapy per year. Cardiac Rehabilitation Therapy has a limit of 36 Visits per year. Post-Cochlear Implant Aural Rehabilitation Therapy has a limit of 30 Visits per year.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Post-Cochlear Implant Aural Rehabilitation Therapy

Limit: 30.0 Visit(s) per Year

YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$55.00

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
YES

$25.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

20.00%

100.00%
Pulmonary Rehabilitation Therapy

Limit: 20.0 Visit(s) per Year

YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

PT/OT Rehabilitative Therapies have a combined limit of 40 Visits per year.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term.

YES

20.00% Coinsurance after deductible

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

Limit: 1.0 Exam(s) per Year

YES

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$65.00

100.00%
Specialty Drugs
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$25.00

100.00%
Transplant
YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$65.00

$65.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

20.00% Coinsurance after deductible

100.00%

Gold 1800 Ded/5600 MOOP Health Insurance Plan Variant 94529WI0240049-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.819161754
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
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
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, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WIF008
Formulary URL URL
HIOS Product ID 94529WI024
Import Date 2/24/2023 1:01
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 Yes
Is a Referral Required for Specialist? Yes
Issuer ID 94529
Issuer Marketplace Marketing Name Group Health Cooperative-SCW
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 20.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $3600 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1800 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,800
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 Gold
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) 94529WI0240049-00
Plan Level Exclusions Prior Authorization, Medically Necessary/Medical Necessity, Act of War, Ongoing Medical Necessity, Experimental/ Investigational Treatment, Service Before Effective Date, Service After Termination Date, Services While Incarcerated, Any Charge for an Appointment a Member does not Attend, Services for Injuries Incurred During the Commission of a Crime
Plan Marketing Name Gold 1800 Ded/5600 MOOP
Plan Type HMO
Plan Variant Marketing Name Gold 1800 Ded/5600 MOOP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,360
SBC Scenario, Having a Baby, Copayment $50
SBC Scenario, Having a Baby, Deductible $1,800
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $500
SBC Scenario, Having Diabetes, Copayment $620
SBC Scenario, Having Diabetes, Deductible $110
SBC Scenario, Having Diabetes, Limit $140
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $60
SBC Scenario, Treatment of a Simple Fracture, Copayment $30
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,800
SBC Scenario, Treatment of a Simple Fracture, Limit $10
Service Area ID WIS001
Source Name HIOS
Specialist Requiring a Referral Allergy, Asthma, Audiology, Cardiovascular, Dermatology, ENT/Otolaryngology, Endocrinology, Gastroenterology, General Surgery, Geriatrics, Hematology, Immunology, Infectious Diseases, Nephrology, Neurology , Neurosurgery, Medical Oncology, Ophthalmology, Orthopedics, Pain Management, Peripheral Vascular, Perinatology, Plastic Surgery, Pulmonology, Radiation Oncology, Rheumatology, Speech Therapy, Spine Medicine, Sports Medicine, Transplant Surgery/Medicine, Urology, Vascular Surgery, All out of area specialty care
Plan ID 94529WI0240049
State Code WI
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 $11200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5600 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,600
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

Copay & Coinsurance of Gold 1800 Ded/5600 MOOP Health Insurance Plan, 94529WI0240049

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

Frequently Asked Questions(FAQ) about Gold 1800 Ded/5600 MOOP, 94529WI0240049 Health Insurance Plan, 94529WI0240049

  • Does Gold 1800 Ded/5600 MOOP Health Insurance Plan, 94529WI0240049 support Mail Ordering?

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

  • Does (94529WI0240049) Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (94529WI0240049) Health Insurance Plan, Variant (94529WI0240049-00) have Out Of Country Coverage?

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

    Does (94529WI0240049) Health Insurance Plan, Variant (94529WI0240049-00) have Out of Service Area Coverage?

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

    Does (94529WI0240049) Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Gold 1800 Ded/5600 MOOP Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs for Asthma?

    Yes, the Gold 1800 Ded/5600 MOOP Health Insurance Plan Variant 94529WI0240049-00 offers Disease Management Program for Asthma.

    Does Gold 1800 Ded/5600 MOOP Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold 1800 Ded/5600 MOOP Health Insurance Plan Variant 94529WI0240049-00 offers Disease Management Program for Heart disease.

    Does Gold 1800 Ded/5600 MOOP Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold 1800 Ded/5600 MOOP Health Insurance Plan Variant 94529WI0240049-00 offers Disease Management Program for Diabetes.

    Does Gold 1800 Ded/5600 MOOP Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold 1800 Ded/5600 MOOP Health Insurance Plan Variant 94529WI0240049-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold 1800 Ded/5600 MOOP Health Insurance Plan, Variant (94529WI0240049-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold 1800 Ded/5600 MOOP Health Insurance Plan Variant 94529WI0240049-00 offers Disease Management Program for Pregnancy.

 

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