Prestige Silver 20 HDHP + Dental + Vision - 81413WI0470007 Health Insurance Plan
Network Health Plan health insurance plan with the Plan ID 81413WI0470007. The plan is called Prestige Silver 20 HDHP + Dental + Vision.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 68.38% (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 31.62% 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 | 81413WI0470007 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Network Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 81413WI0470007-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN002'] | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 81413WI0470007-00 Standard On Exchange Plan - 81413WI0470007-01 Open to Indians below 300% FPL - 81413WI0470007-02 Open to Indians above 300% FPL - 81413WI0470007-03 73% AV Silver Plan - 81413WI0470007-04 |
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| Last Plan Update Date | Fri, 28 Jan 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan Variant 81413WI0470007-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.683782185 |
| 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, Diabetes, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9886 |
| First Tier Utilization | 100% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 81413WI047 |
| Import Date | 1/28/2022 1:00 |
| 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 | 81413 |
| Issuer Marketplace Marketing Name | Network Health |
| Market Coverage | Individual |
| 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 | WIN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 81413WI0470007-00 |
| Plan Marketing Name | Prestige Silver 20 HDHP + Dental + Vision |
| Plan Type | HMO |
| Plan Variant Marketing Name | Prestige Silver 20 HDHP + Dental + Vision |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,820 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $3,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $340 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $3,500 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| 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 | WIS002 |
| Source Name | HIOS |
| Plan ID | 81413WI0470007 |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $7000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,500 |
| 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 | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
| 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 Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, 81413WI0470007
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Prestige Silver 20 HDHP + Dental + Vision, 81413WI0470007 Health Insurance Plan, 81413WI0470007
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Does Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, 81413WI0470007 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (81413WI0470007) Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs
Does (81413WI0470007) Health Insurance Plan, Variant (81413WI0470007-00) have Out Of Country Coverage?
Yes. Details: Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care
Does (81413WI0470007) Health Insurance Plan, Variant (81413WI0470007-00) have Out of Service Area Coverage?
Yes. Details: Emergency Services or Urgent Care Services When services are performed in a free standing urgent care facility or hospital based urgent care
Does (81413WI0470007) Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, Pregnancy, Weight Loss Programs
Does Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs for Asthma?
Yes, the Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan Variant
81413WI0470007-00 offers Disease
Management Program for Asthma.
Does Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs for Heart disease?
Yes, the Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan Variant
81413WI0470007-00 offers Disease
Management Program for Heart disease.
Does Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs for Diabetes?
Yes, the Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan Variant
81413WI0470007-00 offers Disease
Management Program for Diabetes.
Does Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs for Pregnancy?
Yes, the Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan Variant
81413WI0470007-00 offers Disease
Management Program for Pregnancy.
Does Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan, Variant (81413WI0470007-00) offer Disease Management Programs for Weight loss programs?
Yes, the Prestige Silver 20 HDHP + Dental + Vision Health Insurance Plan Variant
81413WI0470007-00 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