HMO Catastrophic 9100 with 3 Free PCP visits - 86584WI0010008 Health Insurance Plan

Aspirus Health Plan, Inc. health insurance plan with the Plan ID 86584WI0010008. The plan is called HMO Catastrophic 9100 with 3 Free PCP visits.

Health Insurance Plan ID 86584WI0010008
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer Aspirus Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 86584WI0010008-00
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 - 86584WI0010008-00

Standard On Exchange Plan - 86584WI0010008-01

Last Plan Update Date Thu, 26 Jan 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan, 86584WI0010008-00

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

Exclusions: No coverage for injuries or damage to teeth, natural or otherwise, as a result of or caused by chewing food or similar substances.

Care must start within 3 months and be completed within 12 months of the injury.

YES

0.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

0.00% Coinsurance after deductible

100.00%
Autism Spectrum Disorders

Up to four years of intensive-level services that commence after you are two years of age and before you are nine years of age.

YES

0.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy

Intravenous chemotherapy is covered.

YES

0.00% Coinsurance after deductible

100.00%
Chiropractic Care

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

YES

0.00% Coinsurance after deductible

100.00%
Clinical Trials
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Dental Anesthesia

Coverage limited to children under age 5 or individuals with a chronic disability or medical condition that requires hospitalization or general anesthesia for dental care.

YES

0.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management
YES

0.00% Coinsurance after deductible

100.00%
Diabetes Education
YES

0.00% Coinsurance after deductible

100.00%
Dialysis
YES

0.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Limit: 1.0 Item(s) per 3 Years

Exclusions: No coverage for rental fees greater than the purchase price, continuous passive motion (CPM) devices, mechanical stretching devices, home spinal traction devices or standers, home INR (international normalized ration blood test) monitors, home phototherapy for dermatological conditions, cold therapy, cryotherapy, home automated external defibrillator (AED), DME with special features that are not medically necessary, DME for your comfort, personal hygiene, or convenience, self-help devices not medical in nature, Routine periodic maintenance, replacement of DME unless medically necessary, replacement of over-the-counter batteries, repairs due to abuse or misuse, light boxes designed for Seasonal Affective Disorder, devices and computers to assist in communication and speech except for speech aid devices and tracheo-esophageal voice devices, blood pressure cuffs and monitors, enuresis alarms, trusses, ultrasonic nebulizers, oral appliances for snoring.

Coverage is limited to a single purchase of a type of DME every 3 years. Coverage is limited to one of the following: a manual wheelchair, a motorized wheelchair, a knee walker, or a motorized scooter. Coverage is limited to one insulin infusion pump per year.

YES

0.00% Coinsurance after deductible

100.00%
Emergency Room Services

Services provided by a non-participating provider will be paid at the participating provider level.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Emergency Transportation/Ambulance

Services provided by a non-participating provider will be paid at the participating provider level.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: No coverage for services provided by a non-participating provider. Contact lenses covered in lieu of all other frames and/or lenses.

Coverage is limited to one pair of eyeglasses (frames and lenses) per year.

YES

0.00% Coinsurance after deductible

100.00%
Gender Affirming Care
NO
Generic Drugs

Limit: 30.0 Item(s) per Month

See brochure for a listing of free preventive drugs.

YES

0.00% Coinsurance after deductible

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for biofeedback.

No coverage for biofeedback.

YES

0.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

Exclusions: No coverage for batteries and cords; or hearing protection equipment.

Coverage is limited to one hearing aid per ear every three years. Coverage is limited to a single purchase (including repair/replacement) every three years for adults.

YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Hospice Services
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

0.00% 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

0.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

MH/SUD office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance.

YES

0.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs

Limit: 30.0 Item(s) per Month

YES

0.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Exclusions: No coverage for weight loss programs.

YES

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

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

0.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for vocational or industrial rehabilitation including work hardening programs; cardiac rehabilitation beyond Phase II; sports hardening and rehabilitation; services by a personal trainer; long-term or maintenance therapy.

Coverage is limited to 20 visits per year for pulmonary rehabilitation; 36 visits per year for cardiac rehabilitation; 30 visits per year for post-cochlear implant aural therpy; 20 visits for cognitive rehabilitation therapy. 20 visit limit for PT, OT and ST.

YES

0.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

0.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Limit: 30.0 Item(s) per Month

YES

0.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

0.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization

Exclusions: No coverage for services provided by a non-participating provider.

YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

MH/SUD office visits are considered the same benefits as a primary care physician.

YES

0.00% Coinsurance after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Limit: 1.0 Item(s) per 3 Years

Coverage limited to a single purchase of a type of prosthetic device every three years.

YES

0.00% Coinsurance after deductible

100.00%
Radiation
YES

0.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Exclusions: No coverage for reduction mammoplasty.

YES

0.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for therapy for attention deficit disorder, hyperactivity disorder, sensory defensiveness, mental retardation, and related conditions; biofeedback; long-term and maintenance therapy.

Coverage is limited to 20 visits per year for physical thearpy and 20 visits per year for occupational thearpy.

YES

0.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: No coverage for long-term and maintenance thearpy.

Coverage is limited to 20 visits per year.

YES

0.00% Coinsurance after deductible

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

Exclusions: Coverage is limited to children through the last day of the calendar month of their 19th birthday; no coverage for services by a non-participating provider."

YES

No Charge

100.00%
Routine Foot Care

Coverage limited to services which are associated with a medical diagnosis of diabetes, peripheral vascular disease, or peripheral neuropathy.

NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

Coverage limited to 30 days per confinement.

YES

0.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

0.00% Coinsurance after deductible

100.00%
Specialty Drugs

Limit: 30.0 Item(s) per Month

YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

MH/SUD office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance.

YES

0.00% Coinsurance after deductible

100.00%
Transplant

Exclusions: No coverage for transplants that are not listed as approved transplant services; expenses related to purchase of any organ;services provided by a non-participating provider.

YES

0.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: No coverage for cosmetic or elective orthodontic care, periodontal care, or general dental care.

YES

0.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities

Services provided by a non-participating provider will be paid at the participating provider level if for emergency medical care.

YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care

Exclusions: No coverage for services provided by a non-participating provider.

YES

0.00% Coinsurance after deductible

100.00%
X-rays and Diagnostic Imaging
YES

0.00% Coinsurance after deductible

100.00%

HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan Variant 86584WI0010008-00 Attributes

Plan Attribute Value
Begin Primary Care Cost-Sharing After Number Of Visits 3
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 Catastrophic Off Exchange Plan
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Heart Disease, Diabetes, High Blood Pressure & High Cholesterol
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WIF001
Formulary URL URL
HIOS Product ID 86584WI001
Import Date 1/26/2023 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 No
Is a Referral Required for Specialist? No
Issuer ID 86584
Issuer Marketplace Marketing Name Aspirus Health Plan
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Catastrophic
Multiple In Network Tiers No
National Network No
Network ID WIN001
Out of Country Coverage No
Out of Country Coverage Description Limited to emergency care only
Out of Service Area Coverage No
Out of Service Area Coverage Description Limited to emergency care only
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 86584WI0010008-00
Plan Marketing Name HMO Catastrophic 9100 with 3 Free PCP visits
Plan Type HMO
Plan Variant Marketing Name HMO Catastrophic 9100 with 3 Free PCP visits
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
SBC Scenario, Having Diabetes, Limit $30
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 $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 86584WI0010008
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
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Combined Medical and Drug EHB Deductible, Out of Network, Individual Not Applicable
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 No

Copay & Coinsurance of HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan, 86584WI0010008

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

Frequently Asked Questions(FAQ) about HMO Catastrophic 9100 with 3 Free PCP visits, 86584WI0010008 Health Insurance Plan, 86584WI0010008

  • Does HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan, 86584WI0010008 support Mail Ordering?

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

  • Does (86584WI0010008) Health Insurance Plan, Variant (86584WI0010008-00) offer Disease Management Programs?

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

    Does (86584WI0010008) Health Insurance Plan, Variant (86584WI0010008-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan). Details: Limited to emergency care only

    Does (86584WI0010008) Health Insurance Plan, Variant (86584WI0010008-00) have Out of Service Area Coverage?

    No, unfortunately there is no Out of Service Area Coverage for this Health Insurance Plan (variant of plan). Details: Limited to emergency care only

    Does (86584WI0010008) Health Insurance Plan, Variant (86584WI0010008-00) offer Disease Management Programs?

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

    Does HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan, Variant (86584WI0010008-00) offer Disease Management Programs for Heart disease?

    Yes, the HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan Variant 86584WI0010008-00 offers Disease Management Program for Heart disease.

    Does HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan, Variant (86584WI0010008-00) offer Disease Management Programs for Diabetes?

    Yes, the HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan Variant 86584WI0010008-00 offers Disease Management Program for Diabetes.

    Does HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan, Variant (86584WI0010008-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the HMO Catastrophic 9100 with 3 Free PCP visits Health Insurance Plan Variant 86584WI0010008-00 offers Disease Management Program for High blood pressure & high cholesterol.

 

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