Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) - 57845WI0040011 Health Insurance Plan
Medica Community Health Plan health insurance plan with the Plan ID 57845WI0040011. The plan is called Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 57845WI0040011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Medica Community Health Plan | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 57845WI0040011-02 | ||||||||||||||||||
| Provider Network(s) | ['WIN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 57845WI0040011-00 Standard On Exchange Plan - 57845WI0040011-01 |
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| Last Plan Update Date | Fri, 28 Oct 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, 57845WI0040011-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 0.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 0.00% |
100.00% |
| Chiropractic Care
|
YES | 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% |
100.00% |
| Emergency Room Services
|
YES | 0.00% |
0.00% |
| Emergency Transportation/Ambulance
|
YES | 0.00% |
0.00% |
| Eye Glasses for Children
|
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 0.00% |
100.00% |
| Generic Drugs
|
YES | 0.00% |
100.00% |
| Habilitation Services
|
YES | 0.00% |
100.00% |
| Hearing Aids
|
YES | 0.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Hospice Services
|
YES | 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 0.00% |
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 | 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 0.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 0.00% |
100.00% |
| Outpatient Rehabilitation Services
|
YES | 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% |
100.00% |
| Preferred Brand Drugs
Prescription insulin will not exceed $25 per prescription unit |
YES | 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Limit of 20 visits for PT, 20 visits for OT |
YES | 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | 0.00% |
100.00% |
| Specialist Visit
|
YES | 0.00% |
100.00% |
| Specialty Drugs
|
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 0.00% |
100.00% |
| Transplant
|
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 0.00% |
0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 0.00% |
100.00% |
Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan Variant 57845WI0040011-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | WIF012 |
| Formulary URL | URL |
| HIOS Product ID | 57845WI004 |
| Import Date | 10/28/2022 1:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 57845 |
| Issuer Marketplace Marketing Name | Medica |
| 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 | WIN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Emergency Services |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Services |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 57845WI0040011-02 |
| Plan Marketing Name | Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) |
| Plan Type | EPO |
| Plan Variant Marketing Name | Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Plan ID | 57845WI0040011 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, 57845WI0040011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers), 57845WI0040011 Health Insurance Plan, 57845WI0040011
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Does Medica Individual Choice Bronze HSA ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, 57845WI0040011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs?
Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-02) have Out Of Country Coverage?
Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-02) have Out of Service Area Coverage?
Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for Asthma?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for Heart disease?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for Depression?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for Diabetes?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for Low back pain?
Does Medica Individual Choice Bronze H ($0 Virtual Care after Deductible with Designated Providers) Health Insurance Plan, Variant (57845WI0040011-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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