HMO Gold 2750 - 86584WI0010007 Health Insurance Plan

Aspirus Health Plan, Inc. health insurance plan with the Plan ID 86584WI0010007. The plan is called HMO Gold 2750.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 76.73% (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 23.27% 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 86584WI0010007
Health Insurance Plan Year 2022
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 86584WI0010007-00
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 - 86584WI0010007-00

Standard On Exchange Plan - 86584WI0010007-01

Open to Indians below 300% FPL - 86584WI0010007-02

Open to Indians above 300% FPL - 86584WI0010007-03

Last Plan Update Date Sat, 18 Dec 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

HMO Gold 2750 Health Insurance Plan Variant 86584WI0010007-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.767312719
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
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 50.00%
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
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 WIF005
Formulary URL URL
HIOS Product ID 86584WI001
Import Date 12/18/2021 3:20
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 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 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $5500 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $2750 per person
Medical EHB Deductible, In Network (Tier 1), Individual $2,750
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 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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 86584WI0010007-00
Plan Marketing Name HMO Gold 2750
Plan Type HMO
Plan Variant Marketing Name HMO Gold 2750
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,750
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,200
SBC Scenario, Having Diabetes, Deductible $800
SBC Scenario, Having Diabetes, Limit $30
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,100
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 86584WI0010007
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 $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,500
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 2750 Health Insurance Plan, 86584WI0010007

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

Frequently Asked Questions(FAQ) about HMO Gold 2750, 86584WI0010007 Health Insurance Plan, 86584WI0010007

  • Does HMO Gold 2750 Health Insurance Plan, 86584WI0010007 support Mail Ordering?

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

  • Does (86584WI0010007) Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs?

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

    Does (86584WI0010007) Health Insurance Plan, Variant (86584WI0010007-00) 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 (86584WI0010007) Health Insurance Plan, Variant (86584WI0010007-00) 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 (86584WI0010007) Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs?

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

    Does HMO Gold 2750 Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs for Asthma?

    Yes, the HMO Gold 2750 Health Insurance Plan Variant 86584WI0010007-00 offers Disease Management Program for Asthma.

    Does HMO Gold 2750 Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs for Heart disease?

    Yes, the HMO Gold 2750 Health Insurance Plan Variant 86584WI0010007-00 offers Disease Management Program for Heart disease.

    Does HMO Gold 2750 Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs for Depression?

    Yes, the HMO Gold 2750 Health Insurance Plan Variant 86584WI0010007-00 offers Disease Management Program for Depression.

    Does HMO Gold 2750 Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs for Diabetes?

    Yes, the HMO Gold 2750 Health Insurance Plan Variant 86584WI0010007-00 offers Disease Management Program for Diabetes.

    Does HMO Gold 2750 Health Insurance Plan, Variant (86584WI0010007-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the HMO Gold 2750 Health Insurance Plan Variant 86584WI0010007-00 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