HMO Silver 4800 - 86584WI0010012 Health Insurance Plan
Aspirus Health Plan, Inc. health insurance plan with the Plan ID 86584WI0010012. The plan is called HMO Silver 4800.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.43% (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 29.57% 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 | 86584WI0010012 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 86584WI0010012-00 | ||||||||||||||||||
| 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 - 86584WI0010012-00 Standard On Exchange Plan - 86584WI0010012-01 Open to Indians below 300% FPL - 86584WI0010012-02 Open to Indians above 300% FPL - 86584WI0010012-03 73% AV Silver Plan - 86584WI0010012-04 |
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| Last Plan Update Date | Sat, 18 Dec 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
HMO Silver 4800 Health Insurance Plan Variant 86584WI0010012-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.704324726 |
| 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 Silver 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 | WIF002 |
| 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 | $9600 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $4800 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,800 |
| 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 | Silver |
| 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) | 86584WI0010012-00 |
| Plan Marketing Name | HMO Silver 4800 |
| Plan Type | HMO |
| Plan Variant Marketing Name | HMO Silver 4800 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $4,800 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| 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 | 86584WI0010012 |
| 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 | $17000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,500 |
| 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 Silver 4800 Health Insurance Plan, 86584WI0010012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about HMO Silver 4800, 86584WI0010012 Health Insurance Plan, 86584WI0010012
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Does HMO Silver 4800 Health Insurance Plan, 86584WI0010012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (86584WI0010012) Health Insurance Plan, Variant (86584WI0010012-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol
Does (86584WI0010012) Health Insurance Plan, Variant (86584WI0010012-00) 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 (86584WI0010012) Health Insurance Plan, Variant (86584WI0010012-00) 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 (86584WI0010012) Health Insurance Plan, Variant (86584WI0010012-00) 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 Silver 4800 Health Insurance Plan, Variant (86584WI0010012-00) offer Disease Management Programs for Asthma?
Yes, the HMO Silver 4800 Health Insurance Plan Variant
86584WI0010012-00 offers Disease
Management Program for Asthma.
Does HMO Silver 4800 Health Insurance Plan, Variant (86584WI0010012-00) offer Disease Management Programs for Heart disease?
Yes, the HMO Silver 4800 Health Insurance Plan Variant
86584WI0010012-00 offers Disease
Management Program for Heart disease.
Does HMO Silver 4800 Health Insurance Plan, Variant (86584WI0010012-00) offer Disease Management Programs for Depression?
Yes, the HMO Silver 4800 Health Insurance Plan Variant
86584WI0010012-00 offers Disease
Management Program for Depression.
Does HMO Silver 4800 Health Insurance Plan, Variant (86584WI0010012-00) offer Disease Management Programs for Diabetes?
Yes, the HMO Silver 4800 Health Insurance Plan Variant
86584WI0010012-00 offers Disease
Management Program for Diabetes.
Does HMO Silver 4800 Health Insurance Plan, Variant (86584WI0010012-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the HMO Silver 4800 Health Insurance Plan Variant
86584WI0010012-00 offers Disease
Management Program for High blood pressure & high cholesterol.
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