SimplyOne $4,000 - 20% HDHP - 38166WI0300010 Health Insurance Plan

Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0300010. The plan is called SimplyOne $4,000 - 20% HDHP.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.04% (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 29.96% 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 38166WI0300010
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 38166WI0300010-00
Provider Network(s) ['WIN005']
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 - 38166WI0300010-00

Standard On Exchange Plan - 38166WI0300010-01

Last Plan Update Date Sat, 15 Jan 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700407111
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, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy, Weight Loss Programs
First Tier Utilization 100%
Formulary ID WIF026
Formulary URL URL
HIOS Product ID 38166WI030
HSA/HRA Employer Contribution No
Import Date 1/15/2022 3:47
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
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 Silver
Multiple In Network Tiers No
National Network No
Network ID WIN005
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) 38166WI0300010-00
Plan Marketing Name SimplyOne $4,000 - 20% HDHP
Plan Type HMO
Plan Variant Marketing Name SimplyOne $4,000 - 20% HDHP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $4,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $20
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $4,000
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 WIS006
Source Name HIOS
Plan ID 38166WI0300010
State Code WI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $10000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $5000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $5,000
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $8000 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $4000 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $4,000
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 $8000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $4000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $4,000
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 $10000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,000
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 SimplyOne $4,000 - 20% HDHP Health Insurance Plan, 38166WI0300010

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

Frequently Asked Questions(FAQ) about SimplyOne $4,000 - 20% HDHP, 38166WI0300010 Health Insurance Plan, 38166WI0300010

  • Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, 38166WI0300010 support Mail Ordering?

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

  • Does (38166WI0300010) Health Insurance Plan, Variant (38166WI0300010-00) 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 (38166WI0300010) Health Insurance Plan, Variant (38166WI0300010-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent Care

    Does (38166WI0300010) Health Insurance Plan, Variant (38166WI0300010-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent Care

    Does (38166WI0300010) Health Insurance Plan, Variant (38166WI0300010-00) 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 SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for Asthma?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 offers Disease Management Program for Asthma.

    Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for Heart disease?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 offers Disease Management Program for Heart disease.

    Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for Depression?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 offers Disease Management Program for Depression.

    Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for Diabetes?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 offers Disease Management Program for Diabetes.

    Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for Pregnancy?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 offers Disease Management Program for Pregnancy.

    Does SimplyOne $4,000 - 20% HDHP Health Insurance Plan, Variant (38166WI0300010-00) offer Disease Management Programs for Weight loss programs?

    Yes, the SimplyOne $4,000 - 20% HDHP Health Insurance Plan Variant 38166WI0300010-00 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