Independence $2,500 - 10% Copay - 38166WI0150040 Health Insurance Plan

Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0150040. The plan is called Independence $2,500 - 10% Copay.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.68% (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 19.32% 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 38166WI0150040
Health Insurance Plan Year 2022
State Wisconsin
Health Insurance Issuer Security Health Plan of Wisconsin, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 38166WI0150040-00
Provider Network(s) ['WIN004']
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 - 38166WI0150040-00

Standard On Exchange Plan - 38166WI0150040-01

Last Plan Update Date Sat, 15 Jan 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.806782389
Begin Primary Care Cost-Sharing After Number Of Visits 1
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 $0 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $0
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 40.00%
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, Pregnancy, Weight Loss Programs
First Tier Utilization 100%
Formulary ID WIF024
Formulary URL URL
HIOS Product ID 38166WI015
HSA/HRA Employer Contribution No
Import Date 1/15/2022 3:47
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? No
Issuer ID 38166
Issuer Marketplace Marketing Name Security Health Plan
Market Coverage SHOP (Small Group)
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $15000 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $7500 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $7,500
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 10.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $5000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $2500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $2,500
Medical EHB Deductible, Out of Network, Family Per Group $10000 per group
Medical EHB Deductible, Out of Network, Family Per Person $5000 per person
Medical EHB Deductible, Out of Network, Individual $5,000
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID WIN004
Out of Country Coverage Yes
Out of Country Coverage Description Urgent and Emergent Care
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Urgent and Emergent Care
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 38166WI0150040-00
Plan Marketing Name Independence $2,500 - 10% Copay
Plan Type POS
Plan Variant Marketing Name Independence $2,500 - 10% Copay
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,000
SBC Scenario, Having a Baby, Copayment $70
SBC Scenario, Having a Baby, Deductible $2,500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,500
SBC Scenario, Having Diabetes, Deductible $200
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $10
SBC Scenario, Treatment of a Simple Fracture, Copayment $80
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS004
Source Name HIOS
Plan ID 38166WI0150040
State Code WI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $33000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $16500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $16,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $11000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $22000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $11000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $11,000
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Independence $2,500 - 10% Copay Health Insurance Plan, 38166WI0150040

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

Frequently Asked Questions(FAQ) about Independence $2,500 - 10% Copay, 38166WI0150040 Health Insurance Plan, 38166WI0150040

  • Does Independence $2,500 - 10% Copay Health Insurance Plan, 38166WI0150040 support Mail Ordering?

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

  • Does (38166WI0150040) Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs?

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

    Does (38166WI0150040) Health Insurance Plan, Variant (38166WI0150040-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent Care

    Does (38166WI0150040) Health Insurance Plan, Variant (38166WI0150040-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent Care

    Does (38166WI0150040) Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs?

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

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for Asthma?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for Asthma.

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for Heart disease?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for Heart disease.

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for Depression?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for Depression.

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for Diabetes?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for Diabetes.

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for Pregnancy?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for Pregnancy.

    Does Independence $2,500 - 10% Copay Health Insurance Plan, Variant (38166WI0150040-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Independence $2,500 - 10% Copay Health Insurance Plan Variant 38166WI0150040-00 offers Disease Management Program for Weight loss programs.

 

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