SimplyOne $2,500 - 20% Copay - 38166WI0300003 Health Insurance Plan
Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0300003. The plan is called SimplyOne $2,500 - 20% Copay.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.73% (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 20.27% 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 | 38166WI0300003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 38166WI0300003-00 | ||||||||||||||||||
| Provider Network(s) | 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). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 31 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
SimplyOne $2,500 - 20% Copay Health Insurance Plan Variant 38166WI0300003-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7972587166512869 |
| 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 | 20.00% |
| 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, Depression, Diabetes, Heart Disease, Pregnancy, Weight Loss Programs |
| First Tier Utilization | 100% |
| Formulary ID | WIF040 |
| Formulary URL | URL |
| HIOS Product ID | 38166WI030 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2024-10-31 01:01:26 |
| 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 | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $5000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $2500 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $2,500 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| 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 | WIN007 |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 38166WI0300003-00 |
| Plan Marketing Name | SimplyOne $2,500 - 20% Copay |
| Plan Type | HMO |
| Plan Variant Marketing Name | SimplyOne $2,500 - 20% Copay |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $30 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| 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 | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS007 |
| Source Name | HIOS |
| Plan ID | 38166WI0300003 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $12000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $6000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $6,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $12000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,000 |
| 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 $2,500 - 20% Copay Health Insurance Plan, 38166WI0300003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SimplyOne $2,500 - 20% Copay, 38166WI0300003 Health Insurance Plan, 38166WI0300003
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Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, 38166WI0300003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38166WI0300003) Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs?
Does (38166WI0300003) Health Insurance Plan, Variant (38166WI0300003-00) have Out Of Country Coverage?
Does (38166WI0300003) Health Insurance Plan, Variant (38166WI0300003-00) have Out of Service Area Coverage?
Does (38166WI0300003) Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs?
Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs for Asthma?
Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs for Heart disease?
Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs for Depression?
Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs for Diabetes?
Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs for Pregnancy?
Does SimplyOne $2,500 - 20% Copay Health Insurance Plan, Variant (38166WI0300003-00) offer Disease Management Programs for Weight loss programs?
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