Select $3,500 - 30% - 38166WI0180023 Health Insurance Plan

Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0180023. The plan is called Select $3,500 - 30%.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.34% (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 21.66% 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 38166WI0180023
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 38166WI0180023-00
Provider Network(s) PREFERRED NON-PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT).

Providers Wisconsin All US States
All 11828 16362
PCP 1397 2299
Allergy 8 9
OB/GYN 46 75
Dentists 122 134
Available Variants of the Health Plan

Standard Off Exchange Plan - 38166WI0180023-00

Standard On Exchange Plan - 38166WI0180023-01

Open to Indians below 300% FPL - 38166WI0180023-02

Open to Indians above 300% FPL - 38166WI0180023-03

Last Plan Update Date Thu, 31 Oct 2024 00:00 GMT
Last Import Date Tue, 13 May 2025 06:05 GMT

Select $3,500 - 30% Health Insurance Plan Variant 38166WI0180023-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7833548914247379
Begin Primary Care Cost-Sharing After Number Of Visits 1
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 Gold Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $0
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID WIF034
Formulary URL URL
HIOS Product ID 38166WI018
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 No
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 No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group $7000 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $3500 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $3,500
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $7000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $3500 per person
Medical EHB Deductible, In Network (Tier 1), Individual $3,500
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID WIN001
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) 38166WI0180023-00
Plan Marketing Name Select $3,500 - 30%
Plan Type EPO
Plan Variant Marketing Name Select $3,500 - 30%
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $30
SBC Scenario, Having a Baby, Deductible $3,500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,500
SBC Scenario, Having Diabetes, Deductible $500
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $80
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,600
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 38166WI0180023
State Code WI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $6,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $13000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $6500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $6,500
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 Select $3,500 - 30% Health Insurance Plan, 38166WI0180023

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

Frequently Asked Questions(FAQ) about Select $3,500 - 30%, 38166WI0180023 Health Insurance Plan, 38166WI0180023

  • Does Select $3,500 - 30% Health Insurance Plan, 38166WI0180023 support Mail Ordering?

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

  • Does (38166WI0180023) Health Insurance Plan, Variant (38166WI0180023-00) have Out Of Country Coverage?

    Yes. Details: Urgent and Emergent Care only

    Does (38166WI0180023) Health Insurance Plan, Variant (38166WI0180023-00) have Out of Service Area Coverage?

    Yes. Details: Urgent and Emergent Care only

 

Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 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