Select Gold 1600 Ded/5400 MOOP - 94529WI0240017 Health Insurance Plan
Group Health Cooperative of South Central Wisconsin health insurance plan with the Plan ID 94529WI0240017. The plan is called Select Gold 1600 Ded/5400 MOOP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.96% (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 18.04% 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 | 94529WI0240017 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Group Health Cooperative of South Central Wisconsin | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 94529WI0240017-00 | ||||||||||||||||||
| Provider Network(s) | ['WIN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 94529WI0240017-00 Standard On Exchange Plan - 94529WI0240017-01 |
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| Last Plan Update Date | Thu, 15 Jul 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
Select Gold 1600 Ded/5400 MOOP Health Insurance Plan Variant 94529WI0240017-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.819647937 |
| 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 Gold Off Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 0.9947 |
| First Tier Utilization | 100% |
| Formulary ID | WIF008 |
| Formulary URL | URL |
| HIOS Product ID | 94529WI024 |
| Import Date | 7/15/2021 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 | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 94529 |
| Issuer Marketplace Marketing Name | Group Health Cooperative-SCW |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $3200 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $1600 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $1,600 |
| 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 | WIN002 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 94529WI0240017-00 |
| Plan Level Exclusions | Prior Authorization, Medically Necessary/Medical Necessity, Act of War, Ongoing Medical Necessity, Experimental/ Investigational Treatment, Service Before Effective Date, Service After Termination Date, Services While Incarcerated, Any Charge for an Appointment a Member does not Attend, Services for Injuries Incurred During the Commission of a Crime |
| Plan Marketing Name | Select Gold 1600 Ded/5400 MOOP |
| Plan Type | HMO |
| Plan Variant Marketing Name | Select Gold 1600 Ded/5400 MOOP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,400 |
| SBC Scenario, Having a Baby, Copayment | $50 |
| SBC Scenario, Having a Baby, Deductible | $1,600 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $500 |
| SBC Scenario, Having Diabetes, Copayment | $620 |
| SBC Scenario, Having Diabetes, Deductible | $110 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,740 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $100 |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Allergy, Asthma, Audiology, Cardiovascular, Dermatology, ENT/Otolaryngology, Endocrinology, Gastroenterology, General Surgery, Geriatrics, Hematology, Immunology, Infectious Diseases, Nephrology, Neurology , Neurosurgery, Medical Oncology, Ophthalmology, Orthopedics, Pain Management, Peripheral Vascular, Perinatology, Plastic Surgery, Pulmonology, Radiation Oncology, Rheumatology, Speech Therapy, Spine Medicine, Sports Medicine, Transplant Surgery/Medicine, Urology, Vascular Surgery, All out of area specialty care |
| Plan ID | 94529WI0240017 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $10800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,400 |
| 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 Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, 94529WI0240017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Select Gold 1600 Ded/5400 MOOP, 94529WI0240017 Health Insurance Plan, 94529WI0240017
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Does Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, 94529WI0240017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94529WI0240017) Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does (94529WI0240017) Health Insurance Plan, Variant (94529WI0240017-00) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (94529WI0240017) Health Insurance Plan, Variant (94529WI0240017-00) have Out of Service Area Coverage?
No, unfortunately there
is no Out of Service Area Coverage for this Health Insurance
Plan (variant of plan).
Does (94529WI0240017) Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Does Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs for Asthma?
Yes, the Select Gold 1600 Ded/5400 MOOP Health Insurance Plan Variant
94529WI0240017-00 offers Disease
Management Program for Asthma.
Does Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs for Heart disease?
Yes, the Select Gold 1600 Ded/5400 MOOP Health Insurance Plan Variant
94529WI0240017-00 offers Disease
Management Program for Heart disease.
Does Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs for Diabetes?
Yes, the Select Gold 1600 Ded/5400 MOOP Health Insurance Plan Variant
94529WI0240017-00 offers Disease
Management Program for Diabetes.
Does Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Select Gold 1600 Ded/5400 MOOP Health Insurance Plan Variant
94529WI0240017-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Select Gold 1600 Ded/5400 MOOP Health Insurance Plan, Variant (94529WI0240017-00) offer Disease Management Programs for Pregnancy?
Yes, the Select Gold 1600 Ded/5400 MOOP Health Insurance Plan Variant
94529WI0240017-00 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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