Atlas $1,500 w/Copay P-S Gold - 20173WI0130040 Health Insurance Plan

HealthPartners Insurance Company health insurance plan with the Plan ID 20173WI0130040. The plan is called Atlas $1,500 w/Copay P-S Gold.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 78.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 22.00% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.02% (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 21.98% 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 20173WI0130040
Health Insurance Plan Year 2024
State Wisconsin
Health Insurance Issuer HealthPartners Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 20173WI0130040-03
Provider Network(s) NETWORK
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT).

Providers Wisconsin All US States
All 4 9
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists 3 3
Available Variants of the Health Plan

Standard On Exchange Plan - 20173WI0130040-01

Open to Indians below 300% FPL - 20173WI0130040-02

Open to Indians above 300% FPL - 20173WI0130040-03

Last Plan Update Date Tue, 19 Dec 2023 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Atlas $1,500 w/Copay P-S Gold Health Insurance Plan, 20173WI0130040-03

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$60.00

50.00% Coinsurance after deductible
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care
YES

$60.00

50.00% Coinsurance after deductible
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

50.00% Coinsurance after deductible
Dialysis
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Limited to one pair of eyeglasses (lenses and frames), or one pair of contact lenses per calendar year

YES

25.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs
YES

$15.00

50.00% Coinsurance after deductible
Habilitation Services

Limit: 20.0 Visit(s) per Year

YES

$30.00

50.00% Coinsurance after deductible
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

$30.00

100.00%
Hospice Services

Limit: 30.0 Days per Episode

Respite care is limited to 5 days per episode, and respite and continuous care combined are limited to 30 days.

YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$30.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$60.00

50.00% Coinsurance after deductible
Nutritional Counseling
YES

No Charge

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$60.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

YES

$30.00

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$30.00

50.00% Coinsurance after deductible
Prenatal and Postnatal Care
YES

No Charge

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

0.00%

50.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

$30.00

50.00% Coinsurance after deductible
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

YES

$30.00

50.00% Coinsurance after deductible
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

YES

$30.00

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

No Charge

50.00% Coinsurance after deductible
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

days per confinement

YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$60.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$30.00

50.00% Coinsurance after deductible
Transplant
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$45.00

50.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

50.00% Coinsurance after deductible

Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7802
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Limited Cost Sharing Plan Variation
Dental Only Plan No
Design Type Design 1
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 0.9990000000000001
First Tier Utilization 100%
Formulary ID WIF006
Formulary URL URL
HIOS Product ID 20173WI013
Import Date 2023-12-19 01:01:03
Limited Cost Sharing Plan Variation - Estimated Advanced Payment 0
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 Actuarial Value 78.00%
Issuer ID 20173
Issuer Marketplace Marketing Name HealthPartners
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID WIN001
Out of Country Coverage Yes
Out of Country Coverage Description Coverage for emergency services only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Out-of-Network benefits will be applied
Plan Brochure URL
Plan Effective Date 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 20173WI0130040-03
Plan Marketing Name Atlas $1,500 w/Copay P-S Gold
Plan Type PPO
Plan Variant Marketing Name Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold
QHP/Non QHP On the Exchange
SBC Scenario, Having a Baby, Coinsurance $2,700
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $70
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $700
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 20173WI0130040
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
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group $40000 per group
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person $20000 per person
Combined Medical and Drug EHB Deductible, Out of Network, Individual $20,000
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 Yes
URL for Summary of Benefits & Coverage URL
Wellness Program Offered Yes

Copay & Coinsurance of Atlas $1,500 w/Copay P-S Gold Health Insurance Plan, 20173WI0130040

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

Frequently Asked Questions(FAQ) about Atlas $1,500 w/Copay P-S Gold, 20173WI0130040 Health Insurance Plan, 20173WI0130040

  • Does Atlas $1,500 w/Copay P-S Gold Health Insurance Plan, 20173WI0130040 support Mail Ordering?

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

  • Does (20173WI0130040) Health Insurance Plan, Variant (20173WI0130040-03) 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 (20173WI0130040) Health Insurance Plan, Variant (20173WI0130040-03) have Out Of Country Coverage?

    Yes. Details: Coverage for emergency services only

    Does (20173WI0130040) Health Insurance Plan, Variant (20173WI0130040-03) have Out of Service Area Coverage?

    Yes. Details: Out-of-Network benefits will be applied

    Does (20173WI0130040) Health Insurance Plan, Variant (20173WI0130040-03) 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 Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Asthma?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Asthma.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Heart disease?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Heart disease.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Depression?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Depression.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Diabetes?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Diabetes.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Low back pain?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Low back pain.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Pregnancy?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Pregnancy.

    Does Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan, Variant (20173WI0130040-03) offer Disease Management Programs for Weight loss programs?

    Yes, the Atlas $1,500 w/Copay P-S Limited Cost Sharing Gold Health Insurance Plan Variant 20173WI0130040-03 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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