Wellmark Bronze Modified HMO - 25896IA0370001 Health Insurance Plan
Wellmark Health Plan of Iowa, Inc. health insurance plan with the Plan ID 25896IA0370001. The plan is called Wellmark Bronze Modified HMO.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.55% (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 36.45% 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 | 25896IA0370001 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Iowa | ||||||||||||||||||
| Health Insurance Issuer | Wellmark Health Plan of Iowa, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 25896IA0370001-00 | ||||||||||||||||||
| Provider Network(s) | ['IAN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 30 Apr 2024 06:06 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 25896IA0370001-00 Standard On Exchange Plan - 25896IA0370001-01 |
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| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 30 Apr 2024 06:06 GMT |
Wellmark Bronze Modified HMO Health Insurance Plan Variant 25896IA0370001-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.635543383 |
| 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 Bronze Off Exchange Plan |
| Dental Only Plan | No |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 1 |
| First Tier Utilization | 100% |
| Formulary ID | IAF001 |
| Formulary URL | URL |
| HIOS Product ID | 25896IA037 |
| Import Date | 8/18/2021 20:00 |
| 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 | 25896 |
| Issuer Marketplace Marketing Name | Wellmark Health Plan of Iowa, Inc. |
| 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 | IAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidental injury and emergency services only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Accidental injury and emergency services only |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan ID (Standard Component ID with Variant) | 25896IA0370001-00 |
| Plan Marketing Name | Wellmark Bronze Modified HMO |
| Plan Type | HMO |
| Plan Variant Marketing Name | Wellmark Bronze Modified HMO |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $8,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,000 |
| SBC Scenario, Having Diabetes, Deductible | $50 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | IAS001 |
| Source Name | SERFF |
| Plan ID | 25896IA0370001 |
| State Code | IA |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| 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 | $17400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8700 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,700 |
| 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 | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Wellmark Bronze Modified HMO Health Insurance Plan, 25896IA0370001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Wellmark Bronze Modified HMO, 25896IA0370001 Health Insurance Plan, 25896IA0370001
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Does Wellmark Bronze Modified HMO Health Insurance Plan, 25896IA0370001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (25896IA0370001) Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does (25896IA0370001) Health Insurance Plan, Variant (25896IA0370001-00) have Out Of Country Coverage?
Yes. Details: Accidental injury and emergency services only
Does (25896IA0370001) Health Insurance Plan, Variant (25896IA0370001-00) have Out of Service Area Coverage?
Yes. Details: Accidental injury and emergency services only
Does (25896IA0370001) Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Asthma?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Asthma.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Heart disease?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Heart disease.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Depression?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Depression.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Diabetes?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Diabetes.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for High blood pressure & high cholesterol.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Low back pain?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Low back pain.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Pregnancy?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Pregnancy.
Does Wellmark Bronze Modified HMO Health Insurance Plan, Variant (25896IA0370001-00) offer Disease Management Programs for Weight loss programs?
Yes, the Wellmark Bronze Modified HMO Health Insurance Plan Variant
25896IA0370001-00 offers Disease
Management Program for Weight loss programs.
Disclaimer: This is based on the import(Date: Tue, 30 Apr 2024 06:06 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