Premier $6,200 HDHP - 38166WI0310005 Health Insurance Plan

Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0310005. The plan is called Premier $6,200 HDHP.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.00% (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 36.00% 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 38166WI0310005
Health Insurance Plan Year 2025
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 38166WI0310005-00
Provider Network(s) PREFERRED NON-PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Wisconsin All US States
All 11504 13783
PCP 1370 1762
Allergy 8 9
OB/GYN 42 54
Dentists 132 145
Available Variants of the Health Plan

Standard Off Exchange Plan - 38166WI0310005-00

Standard On Exchange Plan - 38166WI0310005-01

Open to Indians below 300% FPL - 38166WI0310005-02

Open to Indians above 300% FPL - 38166WI0310005-03

Last Plan Update Date Thu, 31 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Premier $6,200 HDHP Health Insurance Plan, 38166WI0310005-00

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
NO
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

$450.00 Copay 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 Gender affirming services 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

$5.00 Copay 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

$250.00 Copay 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

$250.00 Copay per Day 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

$250.00 Copay per Day 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

$150.00 Copay 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

$80.00 Copay 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

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)
NO
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

No Charge after deductible, 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

$75.00 Copay 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

45.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

$250.00 Copay per Day 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

$75.00 Copay after deductible, No Charge after deductible

$75.00 Copay 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%

Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.63999859636009
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
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, Depression, Diabetes, Pregnancy, Weight Loss Programs
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID WIF037
Formulary URL URL
HIOS Product ID 38166WI031
Import Date 2024-10-31 01:01:26
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? No
Issuer ID 38166
Issuer Marketplace Marketing Name Security Health Plan
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 WIN003
Out of Country Coverage Yes
Out of Country Coverage Description Urgent and Emergent Care only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Urgent and Emergent Care only
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 38166WI0310005-00
Plan Marketing Name Premier $6,200 HDHP
Plan Type HMO
Plan Variant Marketing Name Premier $6,200 HDHP
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $300
SBC Scenario, Having a Baby, Deductible $6,200
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 WIS003
Source Name HIOS
Plan ID 38166WI0310005
State Code WI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $15100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $7550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $7,550
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group $12400 per group
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person $6200 per person
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual $6,200
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 $12400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $6200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $6,200
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 $15100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,550
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 Premier $6,200 HDHP Health Insurance Plan, 38166WI0310005

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

Frequently Asked Questions(FAQ) about Premier $6,200 HDHP, 38166WI0310005 Health Insurance Plan, 38166WI0310005

  • Does Premier $6,200 HDHP Health Insurance Plan, 38166WI0310005 support Mail Ordering?

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

  • Does (38166WI0310005) Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs?

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

    Does (38166WI0310005) Health Insurance Plan, Variant (38166WI0310005-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent Care only

    Does (38166WI0310005) Health Insurance Plan, Variant (38166WI0310005-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent Care only

    Does (38166WI0310005) Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs?

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

    Does Premier $6,200 HDHP Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs for Asthma?

    Yes, the Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 offers Disease Management Program for Asthma.

    Does Premier $6,200 HDHP Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs for Heart disease?

    Yes, the Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 offers Disease Management Program for Heart disease.

    Does Premier $6,200 HDHP Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs for Depression?

    Yes, the Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 offers Disease Management Program for Depression.

    Does Premier $6,200 HDHP Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs for Diabetes?

    Yes, the Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 offers Disease Management Program for Diabetes.

    Does Premier $6,200 HDHP Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs for Pregnancy?

    Yes, the Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 offers Disease Management Program for Pregnancy.

    Does Premier $6,200 HDHP Health Insurance Plan, Variant (38166WI0310005-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Premier $6,200 HDHP Health Insurance Plan Variant 38166WI0310005-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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