EMI Health Premier PPO (High) - 69380WI0040001 Health Insurance Plan
Companion Life Insurance Company health insurance plan with the Plan ID 69380WI0040001. The plan is called EMI Health Premier PPO (High).
| Health Insurance Plan ID | 69380WI0040001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Companion Life Insurance Company | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69380WI0040001-01 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Wed, 14 Jun 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of EMI Health Premier PPO (High) Health Insurance Plan, 69380WI0040001-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Accidental Dental
|
NO | ||
| Basic Dental Care - Adult
Exclusions: Space Maintainers not covered after the end of the month the enrollee turns age 19. Fillings on the same surface 1 every 18 months. Basic benefits covered after 6 month waiting period. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Basic Dental Care - Child
Exclusions: Space Maintainers not covered after the end of the month the enrollee turns age 19. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Limit applies to Exams and Cleanings. Vertical Bitewing X-rays up to 8 films every 6 months. Panoramic X-Ray is allowed 1 every 3 years. Sealants are covered 1 per tooth every 36 months. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Major Dental Care - Adult
Exclusions: Anesthesia only covered when medically or dentally necessary. Implants are not covered. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth. Waiting period applies. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Major Dental Care - Child
Exclusions: Anesthesia is only covered when medically or dentally necessary. Implants not covered after the end of the month the enrollee turns age 19. Crowns, Pontics, Abutments, Onlays and Dentures are covered 1 every 5 years per tooth. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Exclusions: Covered up to the end of the month the enrollee turns age 19. No waiting period applies for Medically Necessary Orthodontia. Orthodontics benefits that are not medically necessary covered after 24 month waiting period. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 50.00% |
50.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Limit applies to Exams and Cleanings. Vertical Bitewing X-rays up to 8 films every 6 months. Panoramic X-Ray is allowed 1 every 3 years. Fluoride and Sealants not covered after the end of the month the enrollee turns age 19. Benefits illustrated are in summary only. Refer to the plan brochure for additional details. |
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
EMI Health Premier PPO (High) Health Insurance Plan Variant 69380WI0040001-01 Attributes
| Plan Attribute | Value |
|---|---|
| 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 | Standard High On Exchange Plan |
| Dental Only Plan | Yes |
| EHB Apportionment for Pediatric Dental | 0.915812768289425 |
| First Tier Utilization | 100% |
| HIOS Product ID | 69380WI004 |
| Import Date | 2023-06-14 01:01:17 |
| Inpatient Copayment Maximum Days | 0 |
| Guaranteed Rate | Guaranteed Rate |
| New/Existing Plan | New |
| Issuer ID | 69380 |
| Issuer Marketplace Marketing Name | Companion Life Insurance Company |
| Market Coverage | Individual |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Group | $750 per group |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out Network, Family Per Person | $375 per person |
| Maximum Out of Pocket for Medical EHB Benefits, Combined In/Out | $375 |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $75 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $25 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $25 |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | per group not applicable |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | per person not applicable |
| Medical EHB Deductible, In Network (Tier 1), Individual | Not Applicable |
| 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 |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, In Network (Tier 1), Individual | Not Applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical EHB Benefits, Out of Network, Individual | Not Applicable |
| Metal Level | High |
| Multiple In Network Tiers | No |
| National Network | Yes |
| Network ID | WIN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Dental expenses for care, supplies, or services which are rendered by a Provider whose principal place of business or address for payment is located outside the United States are payable under the Plan, subject to all Plan exclusions, limitations, maximums and other provisions, under the conditions outlined in the policy. |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | PPO network or out-of-network coverage at PPO fee |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 69380WI0040001-01 |
| Plan Marketing Name | EMI Health Premier PPO (High) |
| Plan Type | PPO |
| Plan Variant Marketing Name | EMI Health Premier PPO (High) |
| QHP/Non QHP | On the Exchange |
| Service Area ID | WIS001 |
| Source Name | HIOS |
| Plan ID | 69380WI0040001 |
| State Code | WI |
| URL for Enrollment Payment | URL |
Copay & Coinsurance of EMI Health Premier PPO (High) Health Insurance Plan, 69380WI0040001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about EMI Health Premier PPO (High), 69380WI0040001 Health Insurance Plan, 69380WI0040001
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Does EMI Health Premier PPO (High) Health Insurance Plan, 69380WI0040001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69380WI0040001) Health Insurance Plan, Variant (69380WI0040001-01) have Out Of Country Coverage?
Does (69380WI0040001) Health Insurance Plan, Variant (69380WI0040001-01) have Out of Service Area Coverage?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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