HMO Gold 2000 - 86584WI0010015 Health Insurance Plan
Aspirus Health Plan, Inc. health insurance plan with the Plan ID 86584WI0010015. The plan is called HMO Gold 2000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 86584WI0010015 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 86584WI0010015-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 86584WI0010015-00 Standard On Exchange Plan - 86584WI0010015-01 |
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| Last Plan Update Date | Thu, 26 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of HMO Gold 2000 Health Insurance Plan, 86584WI0010015-00
| 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 | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $30.00 |
100.00% |
| Clinical Trials
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
Services provided by a non-participating provider will be paid at the participating provider level. |
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
Services provided by a non-participating provider will be paid at the participating provider level. |
YES | 25.00% Coinsurance after deductible |
25.00% 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 | No Charge |
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 | $15.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: No coverage for biofeedback. No coverage for biofeedback. |
YES | 25.00% 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 | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% 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 | 25.00% 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 | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | $60.00 |
100.00% |
| Nutritional Counseling
Exclusions: No coverage for weight loss programs. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% 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 | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Limit: 30.0 Item(s) per Month |
YES | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Exclusions: No coverage for services provided by a non-participating provider. |
YES | 0.00% |
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 | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Exclusions: No coverage for reduction mammoplasty. |
YES | 25.00% 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 | $30.00 |
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 | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
Limit: 30.0 Item(s) per Month |
YES | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% 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 | $30.00 |
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 | 25.00% 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 | 25.00% 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 | $45.00 |
$45.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Exclusions: No coverage for services provided by a non-participating provider. |
YES | $30.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
HMO Gold 2000 Health Insurance Plan Variant 86584WI0010015-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780017779 |
| 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 |
| Dental Only Plan | No |
| Design Type | Design 1 |
| Disease Management Programs Offered | Heart Disease, Diabetes, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | WIF005 |
| 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 | New |
| 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 | Gold |
| 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) | 86584WI0010015-00 |
| Plan Marketing Name | HMO Gold 2000 |
| Plan Type | HMO |
| Plan Variant Marketing Name | HMO Gold 2000 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,400 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $800 |
| SBC Scenario, Having Diabetes, Limit | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS001 |
| Source Name | HIOS |
| Plan ID | 86584WI0010015 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| 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 | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 Gold 2000 Health Insurance Plan, 86584WI0010015
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HMO Gold 2000, 86584WI0010015 Health Insurance Plan, 86584WI0010015
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Does HMO Gold 2000 Health Insurance Plan, 86584WI0010015 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (86584WI0010015) Health Insurance Plan, Variant (86584WI0010015-00) offer Disease Management Programs?
Does (86584WI0010015) Health Insurance Plan, Variant (86584WI0010015-00) have Out Of Country Coverage?
Does (86584WI0010015) Health Insurance Plan, Variant (86584WI0010015-00) have Out of Service Area Coverage?
Does (86584WI0010015) Health Insurance Plan, Variant (86584WI0010015-00) offer Disease Management Programs?
Does HMO Gold 2000 Health Insurance Plan, Variant (86584WI0010015-00) offer Disease Management Programs for Heart disease?
Does HMO Gold 2000 Health Insurance Plan, Variant (86584WI0010015-00) offer Disease Management Programs for Diabetes?
Does HMO Gold 2000 Health Insurance Plan, Variant (86584WI0010015-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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