Independence $4,000 - 20% HDHP - 38166WI0150012 Health Insurance Plan
Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0150012. The plan is called Independence $4,000 - 20% HDHP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.04% (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 29.96% 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 | 38166WI0150012 | ||||||||||||||||||
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| 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 | 38166WI0150012-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN004'] | ||||||||||||||||||
| 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 | |||||||||||||||||||
| Last Plan Update Date | Sat, 15 Jan 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Independence $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0150012-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700407111 |
| 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 |
| 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 | WIF026 |
| 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 | Yes |
| 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 | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| 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) | 38166WI0150012-00 |
| Plan Marketing Name | Independence $4,000 - 20% HDHP |
| Plan Type | POS |
| Plan Variant Marketing Name | Independence $4,000 - 20% HDHP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,000 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $4,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $20 |
| SBC Scenario, Having Diabetes, Copayment | $400 |
| SBC Scenario, Having Diabetes, Deductible | $4,000 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS004 |
| Source Name | HIOS |
| Plan ID | 38166WI0150012 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $30000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $15000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $15,000 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $24000 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $12000 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $12,000 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $8000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,000 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $16000 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $8000 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $8,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $10000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $20000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $10000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $10,000 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Independence $4,000 - 20% HDHP Health Insurance Plan, 38166WI0150012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Independence $4,000 - 20% HDHP, 38166WI0150012 Health Insurance Plan, 38166WI0150012
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Does Independence $4,000 - 20% HDHP Health Insurance Plan, 38166WI0150012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38166WI0150012) Health Insurance Plan, Variant (38166WI0150012-00) 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 (38166WI0150012) Health Insurance Plan, Variant (38166WI0150012-00) have Out Of Country Coverage?
Yes. Details: Urgent and Emergent Care
Does (38166WI0150012) Health Insurance Plan, Variant (38166WI0150012-00) have Out of Service Area Coverage?
Yes. Details: Urgent and Emergent Care
Does (38166WI0150012) Health Insurance Plan, Variant (38166WI0150012-00) 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 $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for Asthma?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for Asthma.
Does Independence $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for Heart disease?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for Heart disease.
Does Independence $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for Depression?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for Depression.
Does Independence $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for Diabetes?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for Diabetes.
Does Independence $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Independence $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for Pregnancy?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for Pregnancy.
Does Independence $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0150012-00) offer Disease Management Programs for Weight loss programs?
Yes, the Independence $4,000 - 20% HDHP Health Insurance Plan Variant
38166WI0150012-00 offers Disease
Management Program for Weight loss programs.
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