Reliance $9,100 - 38166WI0160044 Health Insurance Plan

Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0160044. The plan is called Reliance $9,100.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.86% (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 40.14% 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 38166WI0160044
Health Insurance Plan Year 2023
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 38166WI0160044-00
Provider Network(s) ['WIN002']
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 - 38166WI0160044-00

Standard On Exchange Plan - 38166WI0160044-01

Last Plan Update Date Tue, 11 Oct 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Reliance $9,100 Health Insurance Plan, 38166WI0160044-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

No Charge after deductible, No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible, No Charge after deductible

100.00%
Autism Spectrum Disorders
YES

No Charge after deductible, No Charge after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Cardiac Rehabilitation

Limit: 36.0 Visit(s) per Year

YES

No Charge after deductible, No Charge after deductible

100.00%
Chemotherapy

Intravenous chemotherapy is covered.

YES

No Charge after deductible, No Charge after deductible

100.00%
Chiropractic Care
YES

No Charge after deductible, No Charge after deductible

100.00%
Clinical Trials
YES

No Charge after deductible, No Charge after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Exclusions: Limitations include: prenatal cradle (maternity belt), home delivery and home visits, services performed by a licensed midwife or certified professional midwife, services to determine gender, abortion procedures to end a pregnancy except as specifically stated above.

YES

No Charge after deductible, No Charge after deductible

100.00%
Dental Anesthesia
YES

No Charge after deductible, No Charge after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management
NO
Diabetes Education
YES

No Charge after deductible, No Charge after deductible

100.00%
Dialysis
YES

No Charge after deductible, No Charge after deductible

100.00%
Durable Medical Equipment

Exclusions: Limitations include: routine maintenance and replacement of equipment because of abuse and neglect and urable medical equipment and medical supplies for your comfort, personal hygiene, convenience or athletics-related conditions including, but not limited to, air conditioners, air cleaners, humidifiers, physical fitness equipment, disposable supplies, self-help devices not medical in nature, duplicate pieces of equipment, deluxe/nonstandard equipment and back-up equipment.

YES

No Charge after deductible, No Charge after deductible

100.00%
Emergency Room Services

Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.

YES

No Charge after deductible, No Charge after deductible

No Charge after deductible, No Charge after deductible
Emergency Transportation/Ambulance

Exclusions: Limitations include: Ambulance transport to a home or outpatient setting, medical van transportation, non-emergency licensed professional ambulance services (unless authorized by Security Health Plan), first responders and rescue services and transportation from an acute facility to a sub-acute setting.

YES

No Charge after deductible, No Charge after deductible

No Charge after deductible, No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: Limited to a selection of glasses approved by Security Health Plan

YES

No Charge after deductible, No Charge after deductible

100.00%
Gender Affirming Care

Exclusions: Services covered only Hormone Therapy and Genital reconstructive surgery

NO
Generic Drugs

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

YES

No Charge after deductible, No Charge after deductible

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

No Charge after deductible, No Charge after deductible

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

No Charge after deductible, No Charge after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

YES

No Charge after deductible, No Charge after deductible

100.00%
Hospice Services

Exclusions: Limitations include: financial or legal counseling, including estate planning or drafting of a will, homemaker or caretaker services that are not solely related to the member?s care including, but not limited to, sitter or companion services for the member or the member?s family, transportation, house cleaning, or physical maintenance of the house and pastoral counseling or funeral arrangements.

YES

No Charge after deductible, No Charge after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

No Charge after deductible, No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible, No Charge after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

No Charge after deductible, No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Mental Health Other
NO
Newborn Services Other
NO
Non-Preferred Brand Drugs

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

YES

No Charge after deductible, No Charge after deductible

100.00%
Nutritional Counseling

Exclusions: Covered only when both of the following are true: nutritional education is required for a disease in which patient self-management is an important component of the treatment and there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional

YES

No Charge after deductible, No Charge after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

No Charge after deductible, No Charge after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

No Charge after deductible, No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Rehabilitative services must be short term.

YES

No Charge after deductible, No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Preferred Brand Drugs

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

YES

No Charge after deductible, No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible, No Charge after deductible

100.00%
Prescription Drugs Other
NO
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

No Charge after deductible, No Charge after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

No Charge after deductible, No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible, No Charge after deductible

100.00%
Reconstructive Surgery
YES

No Charge after deductible, No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Rehabilitative services must be short term.

YES

No Charge after deductible, No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders.

Rehabilitative services must be short term.

YES

No Charge after deductible, No Charge after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
YES

No Charge, No Charge after deductible

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

Exclusions: Limitations include: skilled nursing care and/or skilled therapy not prior approved by Security Health Plan and leave-of-absence days, respite care, custodial care, care exceeding the number of days shown in the member?s Schedule of Benefits.

YES

No Charge after deductible, No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible, No Charge after deductible

100.00%
Specialty Drugs

Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary.

YES

No Charge after deductible, No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

No Charge after deductible, No Charge after deductible

100.00%
Transplant

Exclusions: Limitations include: lodging expenses including meals, expenses related to the recipient?s transportation except for medically necessary professionally licensed ambulance services, the purchase price of any bone marrow, organ or tissue that is sold rather than donated, services not ordered by a physician or surgeon, transplants involving non-human or artificial organs or

YES

No Charge after deductible, No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Limit: 4.0 Visit(s) per Year

Exclusions: Limitations include: cosmetic or elective orthodontic care, periodontal care, general dental care, upper and lower jawbone surgery except as required for direct treatment of acute traumatic injury, dislocation, cancer or temporomandibular joint disorder and orthognathic surgery jaw alignment, except as a treatment of obstructive sleep apnea.

YES

No Charge after deductible, No Charge after deductible

100.00%
Urgent Care Centers or Facilities

Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home.

YES

No Charge after deductible, No Charge after deductible

No Charge after deductible, No Charge after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible, No Charge after deductible

100.00%

Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.598552346
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
First Tier Utilization 100%
Formulary ID WIF006
Formulary URL URL
HIOS Product ID 38166WI016
HSA/HRA Employer Contribution No
Import Date 10/11/2022 1:01
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
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 Bronze
Multiple In Network Tiers No
National Network No
Network ID WIN002
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 38166WI0160044-00
Plan Marketing Name Reliance $9,100
Plan Type EPO
Plan Variant Marketing Name Reliance $9,100
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
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 WIS002
Source Name HIOS
Plan ID 38166WI0160044
State Code WI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $9,100
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $9,100
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 $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Yes

Copay & Coinsurance of Reliance $9,100 Health Insurance Plan, 38166WI0160044

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

Frequently Asked Questions(FAQ) about Reliance $9,100, 38166WI0160044 Health Insurance Plan, 38166WI0160044

  • Does Reliance $9,100 Health Insurance Plan, 38166WI0160044 support Mail Ordering?

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

  • Does (38166WI0160044) Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (38166WI0160044) Health Insurance Plan, Variant (38166WI0160044-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent Care

    Does (38166WI0160044) Health Insurance Plan, Variant (38166WI0160044-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent Care

    Does (38166WI0160044) Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Asthma?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 offers Disease Management Program for Asthma.

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Heart disease?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 offers Disease Management Program for Heart disease.

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Depression?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 offers Disease Management Program for Depression.

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Diabetes?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 offers Disease Management Program for Diabetes.

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Low back pain?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 offers Disease Management Program for Low back pain.

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Pregnancy?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 offers Disease Management Program for Pregnancy.

    Does Reliance $9,100 Health Insurance Plan, Variant (38166WI0160044-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Reliance $9,100 Health Insurance Plan Variant 38166WI0160044-00 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