Signature Prestige Bronze Copay + Dental + Vision + Fitness - 81413WI0460018 Health Insurance Plan
Network Health Plan health insurance plan with the Plan ID 81413WI0460018. The plan is called Signature Prestige Bronze Copay + Dental + Vision + Fitness.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.50% (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 35.50% 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 | 81413WI0460018 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Network Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 81413WI0460018-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 81413WI0460018-00 Standard On Exchange Plan - 81413WI0460018-01 |
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| Last Plan Update Date | Fri, 02 Dec 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, 81413WI0460018-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $150.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $150.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | $150.00 |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $75.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $1,500.00 |
100.00% |
| Dental Check-Up for Children
One exam, cleaning, and X-ray per year |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $350.00 |
100.00% |
| Durable Medical Equipment
Will cover 20 DME devices/items per year, whether rented or purchased in accordance with the requirements set out in the Policy. |
YES | $150.00 |
100.00% |
| Emergency Room Services
|
YES | $1,500.00 |
$1,500.00 |
| Emergency Transportation/Ambulance
|
YES | $150.00 |
$150.00 |
| Eye Glasses for Children
1 item per year |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Adherence Generics are available at $0 copay or 0% coinsurance after deductible for certain categories of medications. |
YES | $30.00 |
100.00% |
| Habilitation Services
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. Limited to 20 visits per benefit year for each: Occupational, Speech, and Physical therapy. |
YES | $75.00 |
100.00% |
| Hearing Aids
Covers the cost of basic hearing aids limited to one hearing aid per ear, including repair or replacement, once every three years. |
YES | $150.00 |
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 |
100.00% |
| Hospice Services
|
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $500.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $150.00 |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $150.00 |
100.00% |
| Laboratory Outpatient and Professional Services
A lower copay/coinsurance applies to certain labs for condition management of chronic diseases. |
YES | $75.00 |
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 | $1500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $55.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $55.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $150.00 |
100.00% |
| Outpatient Rehabilitation Services
Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Occupational, Speech, Physical and Pulmonary therapy. Cardiac Rehabilitation Therapy is limited to 36 visits per benefit year. |
YES | $75.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $150.00 |
100.00% |
| Preferred Brand Drugs
|
YES | $160.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Prescription Drugs Other
Formulary Tier 5: Non-preferred specialty drugs |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $55.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Covers up to 10 prosthetic devices that replace a limb or a body part each Benefit Year. |
YES | $300.00 |
100.00% |
| Radiation
|
YES | $150.00 |
100.00% |
| Reconstructive Surgery
|
YES | $150.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per benefit year for each: Occupational and Physical therapy. |
YES | $75.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. Limited to 20 visits per benefit year for each: Speech therapy. |
YES | $75.00 |
100.00% |
| Routine Dental Services (Adult)
One exam, cleaning, and X-ray per year |
YES | No Charge |
100.00% |
| Routine Eye Exam (Adult)
1 Exam per year |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
1 Exam per year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | $1500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $150.00 |
100.00% |
| Specialty Drugs
The coinsurance for Non-preferred specialty drugs is 10% higher than Preferred Specialty drugs. There is No Cost for covered Specialty Drugs for the Native American/Alaskan Limited and Zero Cost share plans. |
YES | 40.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $1500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $55.00 |
100.00% |
| Transplant
|
YES | $1,500.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Coverage for diagnostic procedures and non-surgical treatment limited to 10 services and/or devices per Benefit Year. |
YES | $150.00 |
100.00% |
| Urgent Care Centers or Facilities
Urgent Care Outside the Service Area is only covered when furnished by an Emergency room or Hospital-based Urgent Care Facility. |
YES | $75.00 |
$75.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $150.00 |
100.00% |
Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan Variant 81413WI0460018-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.64503899 |
| 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 |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.99443 |
| First Tier Utilization | 100% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 81413WI046 |
| Import Date | 12/2/2022 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 2 |
| HSA Eligible | No |
| New/Existing Plan | New |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WIN001 |
| 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 81413WI0460018-00 |
| Plan Marketing Name | Signature Prestige Bronze Copay + Dental + Vision + Fitness |
| Plan Type | HMO |
| Plan Variant Marketing Name | Signature Prestige Bronze Copay + Dental + Vision + Fitness |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $3,540 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $3,290 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $60 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,410 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS001 |
| Source Name | HIOS |
| Plan ID | 81413WI0460018 |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | No |
Copay & Coinsurance of Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, 81413WI0460018
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Signature Prestige Bronze Copay + Dental + Vision + Fitness, 81413WI0460018 Health Insurance Plan, 81413WI0460018
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Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, 81413WI0460018 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (81413WI0460018) Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs?
Does (81413WI0460018) Health Insurance Plan, Variant (81413WI0460018-00) have Out Of Country Coverage?
Does (81413WI0460018) Health Insurance Plan, Variant (81413WI0460018-00) have Out of Service Area Coverage?
Does (81413WI0460018) Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs?
Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs for Asthma?
Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs for Heart disease?
Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs for Diabetes?
Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs for Pregnancy?
Does Signature Prestige Bronze Copay + Dental + Vision + Fitness Health Insurance Plan, Variant (81413WI0460018-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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