MercyCare HMO Gold Option C - 58326WI0090013 Health Insurance Plan

MercyCare HMO, Inc. health insurance plan with the Plan ID 58326WI0090013. The plan is called MercyCare HMO Gold Option C.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.59% (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 20.41% 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 58326WI0090013
Health Insurance Plan Year 2022
State Wisconsin
Health Insurance Issuer MercyCare HMO, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 58326WI0090013-00
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 - 58326WI0090013-00

Standard On Exchange Plan - 58326WI0090013-01

Open to Indians below 300% FPL - 58326WI0090013-02

Open to Indians above 300% FPL - 58326WI0090013-03

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

MercyCare HMO Gold Option C Health Insurance Plan Variant 58326WI0090013-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.795897289
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
Dental Only Plan No
Disease Management Programs Offered Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WIF008
Formulary URL URL
HIOS Product ID 58326WI009
Import Date 8/18/2021 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 58326
Issuer Marketplace Marketing Name MercyCare Health Plans
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 services only
Out of Service Area Coverage No
Out of Service Area Coverage Description Limited to emergency services only
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 58326WI0090013-00
Plan Marketing Name MercyCare HMO Gold Option C
Plan Type HMO
Plan Variant Marketing Name MercyCare HMO Gold Option C
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $3,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $3,000
SBC Scenario, Having Diabetes, Limit $55
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 $1,925
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS002
Source Name HIOS
Plan ID 58326WI0090013
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 $6000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $3,000
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 $6000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $3000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $3,000
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 MercyCare HMO Gold Option C Health Insurance Plan, 58326WI0090013

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

Frequently Asked Questions(FAQ) about MercyCare HMO Gold Option C, 58326WI0090013 Health Insurance Plan, 58326WI0090013

  • Does MercyCare HMO Gold Option C Health Insurance Plan, 58326WI0090013 support Mail Ordering?

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

  • Does (58326WI0090013) Health Insurance Plan, Variant (58326WI0090013-00) offer Disease Management Programs?

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

    Does (58326WI0090013) Health Insurance Plan, Variant (58326WI0090013-00) 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 services only

    Does (58326WI0090013) Health Insurance Plan, Variant (58326WI0090013-00) 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 services only

    Does (58326WI0090013) Health Insurance Plan, Variant (58326WI0090013-00) offer Disease Management Programs?

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

    Does MercyCare HMO Gold Option C Health Insurance Plan, Variant (58326WI0090013-00) offer Disease Management Programs for Heart disease?

    Yes, the MercyCare HMO Gold Option C Health Insurance Plan Variant 58326WI0090013-00 offers Disease Management Program for Heart disease.

    Does MercyCare HMO Gold Option C Health Insurance Plan, Variant (58326WI0090013-00) offer Disease Management Programs for Diabetes?

    Yes, the MercyCare HMO Gold Option C Health Insurance Plan Variant 58326WI0090013-00 offers Disease Management Program for Diabetes.

    Does MercyCare HMO Gold Option C Health Insurance Plan, Variant (58326WI0090013-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the MercyCare HMO Gold Option C Health Insurance Plan Variant 58326WI0090013-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does MercyCare HMO Gold Option C Health Insurance Plan, Variant (58326WI0090013-00) offer Disease Management Programs for Low back pain?

    Yes, the MercyCare HMO Gold Option C Health Insurance Plan Variant 58326WI0090013-00 offers Disease Management Program for Low back pain.

 

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