Robin Oak $1,500 w/Copay P-S Gold - 20173WI0130011 Health Insurance Plan
HealthPartners Insurance Company health insurance plan with the Plan ID 20173WI0130011. The plan is called Robin Oak $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 | 20173WI0130011 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 20173WI0130011-01 | ||||||||||||||||||
| 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 - 20173WI0130011-01 |
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| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, 20173WI0130011-01
| 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 |
Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan Variant 20173WI0130011-01 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 | Standard Gold On Exchange Plan |
| 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 | WIN002 |
| 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) | 20173WI0130011-01 |
| Plan Marketing Name | Robin Oak $1,500 w/Copay P-S Gold |
| Plan Type | PPO |
| Plan Variant Marketing Name | Robin Oak $1,500 w/Copay P-S 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 | WIS002 |
| Source Name | HIOS |
| Plan ID | 20173WI0130011 |
| 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 Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, 20173WI0130011
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Robin Oak $1,500 w/Copay P-S Gold, 20173WI0130011 Health Insurance Plan, 20173WI0130011
-
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, 20173WI0130011 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20173WI0130011) Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs?
Does (20173WI0130011) Health Insurance Plan, Variant (20173WI0130011-01) have Out Of Country Coverage?
Does (20173WI0130011) Health Insurance Plan, Variant (20173WI0130011-01) have Out of Service Area Coverage?
Does (20173WI0130011) Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for Asthma?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for Heart disease?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for Depression?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for Diabetes?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for Low back pain?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) offer Disease Management Programs for Pregnancy?
Does Robin Oak $1,500 w/Copay P-S Gold Health Insurance Plan, Variant (20173WI0130011-01) 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