Medica Individual Choice Bronze HSA - 57845WI0040011 Health Insurance Plan

Medica Community Health Plan health insurance plan with the Plan ID 57845WI0040011. The plan is called Medica Individual Choice Bronze HSA.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 61.95% (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 38.05% 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 57845WI0040011
Health Insurance Plan Year 2025
State Wisconsin
Health Insurance Issuer Medica Community Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 57845WI0040011-00
Provider Network(s) PREFERRED PREFERREDTIER STANDARDTIER
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 16049 152285
PCP 1273 14091
Allergy 3 22
OB/GYN 17 360
Dentists 4 24
Available Variants of the Health Plan

Standard Off Exchange Plan - 57845WI0040011-00

Standard On Exchange Plan - 57845WI0040011-01

Open to Indians below 300% FPL - 57845WI0040011-02

Open to Indians above 300% FPL - 57845WI0040011-03

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

Benefits of Medica Individual Choice Bronze HSA Health Insurance Plan, 57845WI0040011-00

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

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing

Exclusions: See policy or plan document for additional benefit exclusions.

YES

20.00% Coinsurance after deductible

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Chiropractic Care
YES

20.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

20.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Dialysis
YES

20.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

20.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

20.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

20.00% Coinsurance after deductible

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 3 Years

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

20.00% Coinsurance after deductible

100.00%
Hospice Services
YES

20.00% Coinsurance after deductible

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

20.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

20.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

20.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

20.00% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

20.00% Coinsurance after deductible

100.00%
Nutritional Counseling

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

20.00% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

20.00% Coinsurance after deductible

100.00%
Prenatal and Postnatal Care
YES

20.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

20.00% Coinsurance after deductible

100.00%
Private-Duty Nursing
NO
Prosthetic Devices

Exclusions: See policy or plan document for additional benefit exclusions.

YES

20.00% Coinsurance after deductible

100.00%
Radiation
YES

20.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Exclusions: See policy or plan document for additional benefit exclusions.

See policy or plan document for additional benefit explanation.

YES

20.00% Coinsurance after deductible

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 30.0 Days per Stay

YES

20.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

20.00% Coinsurance after deductible

100.00%
Specialty Drugs
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

20.00% Coinsurance after deductible

100.00%
Transplant
YES

20.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

20.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

20.00% Coinsurance after deductible

20.00% Coinsurance after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

20.00% Coinsurance after deductible

100.00%

Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.6195432041275319
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 Standard Bronze Off Exchange Plan
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
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID WIF009
Formulary URL URL
HIOS Product ID 57845WI004
Import Date 2024-09-19 01:01:32
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 57845
Issuer Marketplace Marketing Name Medica
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 WIN002
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 57845WI0040011-00
Plan Marketing Name Medica Individual Choice Bronze HSA
Plan Type EPO
Plan Variant Marketing Name Medica Individual Choice Bronze HSA
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $800
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $2,300
SBC Scenario, Having Diabetes, Limit $0
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 $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS004
Source Name HIOS
Plan ID 57845WI0040011
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $14000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,000
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 $16600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8300 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,300
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 No

Copay & Coinsurance of Medica Individual Choice Bronze HSA Health Insurance Plan, 57845WI0040011

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

Frequently Asked Questions(FAQ) about Medica Individual Choice Bronze HSA, 57845WI0040011 Health Insurance Plan, 57845WI0040011

  • Does Medica Individual Choice Bronze HSA Health Insurance Plan, 57845WI0040011 support Mail Ordering?

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

  • Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-00) 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

    Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services

    Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services

    Does (57845WI0040011) Health Insurance Plan, Variant (57845WI0040011-00) 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

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for Asthma?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for Asthma.

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for Heart disease?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for Heart disease.

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for Depression?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for Depression.

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for Diabetes?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for Diabetes.

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for Low back pain?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for Low back pain.

    Does Medica Individual Choice Bronze HSA Health Insurance Plan, Variant (57845WI0040011-00) offer Disease Management Programs for Pregnancy?

    Yes, the Medica Individual Choice Bronze HSA Health Insurance Plan Variant 57845WI0040011-00 offers Disease Management Program for Pregnancy.

 

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