Gold 1 with Adult Vision Services - 52697WI0050001 Health Insurance Plan
Molina Healthcare of Wisconsin, Inc. health insurance plan with the Plan ID 52697WI0050001. The plan is called Gold 1 with Adult Vision Services.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.01% (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 21.99% 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 | 52697WI0050001 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Molina Healthcare of Wisconsin, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 52697WI0050001-03 | ||||||||||||||||||
| Provider Network(s) | ['WIN001'] | ||||||||||||||||||
| 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 | Standard Off Exchange Plan - 52697WI0050001-00 Standard On Exchange Plan - 52697WI0050001-01 |
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| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Gold 1 with Adult Vision Services Health Insurance Plan, 52697WI0050001-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Autism Spectrum Disorders - Intensive Level Services
Limit: 30.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Autism Spectrum Disorders - Non-Intensive Level Services
Limit: 20.0 Visit(s) per Year |
YES | $20.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year |
YES | $20.00 |
100.00% |
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $20.00 |
100.00% |
| Clinical Trials
To qualify for coverage, an enrolled Member must be diagnosed with cancer or other life-threatening disease or condition, be accepted into an Approved Clinical Trial (as defined below) and have received Prior Authorization or approval from Molina. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
Must be medically necessary |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | No Charge |
100.00% |
| Dialysis
|
YES | $50.00 |
100.00% |
| Durable Medical Equipment
Limit: 2500.0 Dollars per Year Benefits are limited to a single purchase of a type of DME (including repair/replacement) every three years. This limit does not apply to wound vacuums. Cochlear implants are included under the Durable Medical Equipment benefit as required by Wisconsin insurance law. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| 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 |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Cost share shown is for a 30 day supply. Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to MolinaMarketplace.com/WIFormulary2024 for formulary information |
YES | $15.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $20.00 |
100.00% |
| Hearing Aids
Limit: 2500.0 Dollars per Year Benefits are limited to a single purchase (including repair/replacement) per hearing impaired ear every three years. For Enrolled Dependent children under age 18, Benefits are limited to one hearing aid per ear, every three years as required by Wisconsin insurance law. Hearing aids for Enrolled Dependent children are not subject to dollar maximums. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. |
YES | No Charge |
100.00% |
| Hospice Services
Limit: 6.0 Months per 3 Years |
YES | No Charge |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $15.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
All inpatient non-emergency Mental Health, Severe Mental Illness or Substance Abuse require Prior Authorization. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
YES | $20.00 |
100.00% |
| Mental/Behavioral Health Outpatient Services - Other
Cost sharing listed matches Outpatient Facility Fee (e.g., Ambulatory Surgery Center) and Outpatient Surgery Phsycian/Surgical Services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
Cost share shown is for a 30 day supply. Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to MolinaMarketplace.com/WIFormulary2024 for formulary informati |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. 20 visits/yr for each service (Physical Therapy, Occupational Therapy, Speech Therapy, and Pulmonary Rehabilitation Therapy) |
YES | $20.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Post-cochlear implant aural therapy
Limit: 30.0 Visit(s) per Year |
YES | $50.00 |
100.00% |
| Preferred Brand Drugs
Cost share shown is for a 30 day supply. Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to MolinaMarketplace.com/WIFormulary2024 for formulary information |
YES | $50.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Limit: 2500.0 Dollars per Year Benefits are limited to a single purchase of each type of prosthetic device every three years. Once this limit is reached, Benefits continue to be available for items required by the Women?s Health and Cancer Rights Act of 1998. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Separate limits for occupational therapy and physical therapy. 20 visits per year limit for occupational therapy and 20 visits per year limit for physical therapy |
YES | $20.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. |
YES | $20.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Benefit Period |
YES | No Charge |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $50.00 |
100.00% |
| Specialty Drugs
Cost share shown is for a 30 day supply. Certain medications in the drug formulary may be subject to quantity and/or age limits consistent with the FDA labeling for the product. Please refer to MolinaMarketplace.com/WIFormulary2024 for formulary informati |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
All inpatient Substance Abuse Disorder services require Prior Authorization. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Cost sharing shown applies to outpatient office visits only. See Summary of Benefits and Coverage, Schedule of Benefits, and the Evidence of Coverage for more information on other MH/SUD outpatient services, which may apply a different cost share amount and require Prior Authorization. |
YES | $20.00 |
100.00% |
| Substance Abuse Disorder Outpatient Services - Other
Cost sharing listed matches Outpatient Facility Fee (e.g., Ambulatory Surgery Center) and Outpatient Surgery Phsycian/Surgical Services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 1250.0 Dollars per Year 1 surgical procedure and 3 visits per year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $20.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Gold 1 LCS with Adult Vision Services Health Insurance Plan Variant 52697WI0050001-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780109691520222 |
| 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 | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.9940200000000001 |
| First Tier Utilization | 100% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 52697WI005 |
| Import Date | 2024-10-17 01:02:25 |
| 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 | 52697 |
| Issuer Marketplace Marketing Name | Molina Healthcare |
| 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 | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 52697WI0050001-03 |
| Plan Marketing Name | Gold 1 with Adult Vision Services |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold 1 LCS with Adult Vision Services |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,400 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| SBC Scenario, Having a Baby, Deductible | $1,600 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $100 |
| SBC Scenario, Having Diabetes, Copayment | $900 |
| SBC Scenario, Having Diabetes, Deductible | $1,600 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS001 |
| Source Name | HIOS |
| Plan ID | 52697WI0050001 |
| 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 | $3280 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1640 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,640 |
| 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 | $16200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,100 |
| 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 Gold 1 with Adult Vision Services Health Insurance Plan, 52697WI0050001
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold 1 with Adult Vision Services, 52697WI0050001 Health Insurance Plan, 52697WI0050001
-
Does Gold 1 with Adult Vision Services Health Insurance Plan, 52697WI0050001 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (52697WI0050001) Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs?
Does (52697WI0050001) Health Insurance Plan, Variant (52697WI0050001-03) have Out Of Country Coverage?
Does (52697WI0050001) Health Insurance Plan, Variant (52697WI0050001-03) have Out of Service Area Coverage?
Does (52697WI0050001) Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs for Asthma?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs for Heart disease?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs for Depression?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs for Diabetes?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs for Pregnancy?
Does Gold 1 LCS with Adult Vision Services Health Insurance Plan, Variant (52697WI0050001-03) offer Disease Management Programs for Weight loss programs?
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