Independence $4,500 - 30% Copay - 38166WI0150036 Health Insurance Plan
Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0150036. The plan is called Independence $4,500 - 30% Copay.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.28% (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 28.72% 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 | 38166WI0150036 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 38166WI0150036-00 | ||||||||||||||||||
| 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). |
|
||||||||||||||||||
| 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 $4,500 - 30% Copay Health Insurance Plan Variant 38166WI0150036-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.712779005 |
| 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 Silver 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 | 45.00% |
| 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 | WIF025 |
| 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 | $27000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $13500 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $13,500 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $9000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $4500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $4,500 |
| Medical EHB Deductible, Out of Network, Family Per Group | $18000 per group |
| Medical EHB Deductible, Out of Network, Family Per Person | $9000 per person |
| Medical EHB Deductible, Out of Network, Individual | $9,000 |
| 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) | 38166WI0150036-00 |
| Plan Marketing Name | Independence $4,500 - 30% Copay |
| Plan Type | POS |
| Plan Variant Marketing Name | Independence $4,500 - 30% Copay |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $70 |
| SBC Scenario, Having a Baby, Deductible | $4,500 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,700 |
| SBC Scenario, Having Diabetes, Deductible | $200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $90 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS004 |
| Source Name | HIOS |
| Plan ID | 38166WI0150036 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $51300 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $25650 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $25,650 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $17100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8550 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,550 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $34200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $17100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $17,100 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Independence $4,500 - 30% Copay Health Insurance Plan, 38166WI0150036
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Independence $4,500 - 30% Copay, 38166WI0150036 Health Insurance Plan, 38166WI0150036
-
Does Independence $4,500 - 30% Copay Health Insurance Plan, 38166WI0150036 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38166WI0150036) Health Insurance Plan, Variant (38166WI0150036-00) 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 (38166WI0150036) Health Insurance Plan, Variant (38166WI0150036-00) have Out Of Country Coverage?
Yes. Details: Urgent and Emergent Care
Does (38166WI0150036) Health Insurance Plan, Variant (38166WI0150036-00) have Out of Service Area Coverage?
Yes. Details: Urgent and Emergent Care
Does (38166WI0150036) Health Insurance Plan, Variant (38166WI0150036-00) 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 $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for Asthma?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 offers Disease
Management Program for Asthma.
Does Independence $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for Heart disease?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 offers Disease
Management Program for Heart disease.
Does Independence $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for Depression?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 offers Disease
Management Program for Depression.
Does Independence $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for Diabetes?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 offers Disease
Management Program for Diabetes.
Does Independence $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Independence $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for Pregnancy?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 offers Disease
Management Program for Pregnancy.
Does Independence $4,500 - 30% Copay Health Insurance Plan, Variant (38166WI0150036-00) offer Disease Management Programs for Weight loss programs?
Yes, the Independence $4,500 - 30% Copay Health Insurance Plan Variant
38166WI0150036-00 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