Atlas $3,500 HSA Silver - 20173WI0130026 Health Insurance Plan
HealthPartners Insurance Company health insurance plan with the Plan ID 20173WI0130026. The plan is called Atlas $3,500 HSA Silver.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% 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 100.00% (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 0.00% 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 | 20173WI0130026 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | HealthPartners Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 20173WI0130026-02 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 20173WI0130026-01 Open to Indians below 300% FPL - 20173WI0130026-02 Open to Indians above 300% FPL - 20173WI0130026-03 73% AV Silver Plan - 20173WI0130026-04 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Atlas $3,500 HSA Silver Health Insurance Plan, 20173WI0130026-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $0.00, 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Chiropractic Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Dialysis
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Durable Medical Equipment
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Room Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Emergency Transportation/Ambulance
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| 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 | $0.00, 0.00% |
100.00% |
| Gender Affirming Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Generic Drugs
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Inpatient Physician and Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Laboratory Outpatient and Professional Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy for detailed information. |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Non-Preferred Brand Drugs
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Nutritional Counseling
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preferred Brand Drugs
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Prenatal and Postnatal Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Radiation
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Reconstructive Surgery
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay Days per Confinement |
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialist Visit
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Specialty Drugs
|
YES | $0.00, 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Transplant
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | $0.00, 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
| X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
$0.00, 0.00% |
Atlas Zero Cost Sharing Silver Health Insurance Plan Variant 20173WI0130026-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| 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 | 0.9991 |
| First Tier Utilization | 100% |
| Formulary ID | WIF003 |
| Formulary URL | URL |
| HIOS Product ID | 20173WI013 |
| Import Date | 2024-10-10 01:01:49 |
| 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 | 100.00% |
| 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 | Silver |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 20173WI0130026-02 |
| Plan Marketing Name | Atlas $3,500 HSA Silver |
| Plan Type | PPO |
| Plan Variant Marketing Name | Atlas Zero Cost Sharing Silver |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $70 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS001 |
| Source Name | HIOS |
| Plan ID | 20173WI0130026 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $0 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, Out of Network, Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | $0 |
| Unique Plan Design | Yes |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Atlas $3,500 HSA Silver Health Insurance Plan, 20173WI0130026
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Atlas $3,500 HSA Silver, 20173WI0130026 Health Insurance Plan, 20173WI0130026
-
Does Atlas $3,500 HSA Silver Health Insurance Plan, 20173WI0130026 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20173WI0130026) Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs?
Does (20173WI0130026) Health Insurance Plan, Variant (20173WI0130026-02) have Out Of Country Coverage?
Does (20173WI0130026) Health Insurance Plan, Variant (20173WI0130026-02) have Out of Service Area Coverage?
Does (20173WI0130026) Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for Asthma?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for Heart disease?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for Depression?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for Diabetes?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for Low back pain?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs for Pregnancy?
Does Atlas Zero Cost Sharing Silver Health Insurance Plan, Variant (20173WI0130026-02) offer Disease Management Programs 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