Robin Select $5,800 w/Copay P-S Silver - 20173WI0130034 Health Insurance Plan

HealthPartners Insurance Company health insurance plan with the Plan ID 20173WI0130034. The plan is called Robin Select $5,800 w/Copay P-S Silver.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.06% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.94% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.06% (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 29.94% 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 20173WI0130034
Health Insurance Plan Year 2023
State Wisconsin
Health Insurance Issuer HealthPartners Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 20173WI0130034-01
Provider Network(s) ['WIN003']
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 On Exchange Plan - 20173WI0130034-01

Open to Indians below 300% FPL - 20173WI0130034-02

Open to Indians above 300% FPL - 20173WI0130034-03

73% AV Silver Plan - 20173WI0130034-04

87% AV Silver Plan - 20173WI0130034-05

94% AV Silver Plan - 20173WI0130034-06

Last Plan Update Date Fri, 24 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, 20173WI0130034-01

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

40.00% Coinsurance after deductible

100%
Acupuncture
NO
Allergy Testing
YES

$80.00

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care
YES

$80.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

50.00% Coinsurance after deductible
Dialysis
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Limited to one pair of eyeglasses (lenses and frames), or one pair of contact lenses per calendar year

YES

40.00% Coinsurance after deductible

100%
Gender Affirming Care
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs
YES

$20.00

50.00% Coinsurance after deductible
Habilitation Services

Limit: 20.0 Visit(s) per Year

YES

$40.00

50.00% Coinsurance after deductible
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

$40.00

100%
Hospice Services

Limit: 30.0 Days per Episode

Respite care is limited to 5 days per episode, and respite and continuous care combined are limited to 30 days.

YES

40.00% Coinsurance after deductible

100%
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$40.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$80.00 Copay after deductible

50.00% Coinsurance after deductible
Nutritional Counseling
YES

No Charge

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$80.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

YES

$40.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$40.00

50.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

No Charge

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

50.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

$40.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

YES

$40.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

YES

$40.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

No Charge

50.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

days per confinement

YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$80.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

$350.00 Copay after deductible

100%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$40.00

50.00% Coinsurance after deductible
Transplant
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

100%
Urgent Care Centers or Facilities
YES

$60.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7006
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 Silver On Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 0.9987
First Tier Utilization 100%
Formulary ID WIF008
Formulary URL URL
HIOS Product ID 20173WI013
Import Date 2/24/2023 1:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer Actuarial Value 70.06%
Issuer ID 20173
Issuer Marketplace Marketing Name HealthPartners
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 WIN003
Out of Country Coverage Yes
Out of Country Coverage Description Coverage for emergency services only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out-of-Network benefits will be applied
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 20173WI0130034-01
Plan Marketing Name Robin Select $5,800 w/Copay P-S Silver
Plan Type PPO
Plan Variant Marketing Name Robin Select $5,800 w/Copay P-S Silver
QHP/Non QHP On the Exchange
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,800
SBC Scenario, Having a Baby, Limit $70
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,300
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS003
Source Name HIOS
Plan ID 20173WI0130034
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $11600 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5800 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,800
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $40000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $20000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $20,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $17800 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8900 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,900
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 Yes
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, 20173WI0130034

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

Frequently Asked Questions(FAQ) about Robin Select $5,800 w/Copay P-S Silver, 20173WI0130034 Health Insurance Plan, 20173WI0130034

  • Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, 20173WI0130034 support Mail Ordering?

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

  • Does (20173WI0130034) Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs?

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

    Does (20173WI0130034) Health Insurance Plan, Variant (20173WI0130034-01) have Out Of Country Coverage?

    Yes. Details: Coverage for emergency services only

    Does (20173WI0130034) Health Insurance Plan, Variant (20173WI0130034-01) have Out of Service Area Coverage?

    Yes. Details: Out-of-Network benefits will be applied

    Does (20173WI0130034) Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs?

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

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Asthma?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for Asthma.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Heart disease?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for Heart disease.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Depression?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for Depression.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Diabetes?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for Diabetes.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Low back pain?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for Low back pain.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Pregnancy?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 offers Disease Management Program for Pregnancy.

    Does Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan, Variant (20173WI0130034-01) offer Disease Management Programs for Weight loss programs?

    Yes, the Robin Select $5,800 w/Copay P-S Silver Health Insurance Plan Variant 20173WI0130034-01 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