Robin Select $8,200 HSA Bronze - 20173WI0130038 Health Insurance Plan
HealthPartners Insurance Company health insurance plan with the Plan ID 20173WI0130038. The plan is called Robin Select $8,200 HSA Bronze.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 61.56% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 38.44% 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 61.61% (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 38.39% 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 | 20173WI0130038 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 20173WI0130038-03 | ||||||||||||||||||
| 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 - 20173WI0130038-01 |
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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 Robin Select $8,200 HSA Bronze Health Insurance Plan, 20173WI0130038-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Chiropractic Care
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge 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 | No Charge after deductible |
50.00% Coinsurance after deductible |
| Durable Medical Equipment
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Emergency Room Services
|
YES | No Charge after deductible |
No Charge after deductible |
| Emergency Transportation/Ambulance
|
YES | No Charge after deductible |
No Charge 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 | No Charge after deductible |
100.00% |
| Gender Affirming Care
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Generic Drugs
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Habilitation Services
Limit: 20.0 Visit(s) per Year |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Laboratory Outpatient and Professional Services
|
YES | No Charge 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 | No Charge after deductible |
50.00% Coinsurance after deductible |
| 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 | No Charge after deductible |
50.00% Coinsurance after deductible |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
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 | No Charge after deductible |
50.00% Coinsurance after deductible |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Preferred Brand Drugs
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Prenatal and Postnatal Care
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
50.00% Coinsurance after deductible |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Radiation
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Reconstructive Surgery
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year |
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year |
YES | No Charge after deductible |
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 | No Charge after deductible |
50.00% Coinsurance after deductible |
| Specialist Visit
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Specialty Drugs
|
YES | No Charge |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Transplant
|
YES | No Charge after deductible |
50.00% Coinsurance after deductible |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
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 | No Charge after deductible |
50.00% Coinsurance after deductible |
Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan Variant 20173WI0130038-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.616128288024735 |
| 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, 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 | WIF001 |
| 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 | 61.56% |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WIN003 |
| 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) | 20173WI0130038-03 |
| Plan Marketing Name | Robin Select $8,200 HSA Bronze |
| Plan Type | PPO |
| Plan Variant Marketing Name | Robin Select $8,200 Limited Cost Sharing Bronze |
| 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 | $8,200 |
| SBC Scenario, Having a Baby, Limit | $70 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| 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 | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS003 |
| Source Name | HIOS |
| Plan ID | 20173WI0130038 |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $16400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8200 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,200 |
| 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 | $16400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,200 |
| 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 Select $8,200 HSA Bronze Health Insurance Plan, 20173WI0130038
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Robin Select $8,200 HSA Bronze, 20173WI0130038 Health Insurance Plan, 20173WI0130038
-
Does Robin Select $8,200 HSA Bronze Health Insurance Plan, 20173WI0130038 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20173WI0130038) Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs?
Does (20173WI0130038) Health Insurance Plan, Variant (20173WI0130038-03) have Out Of Country Coverage?
Does (20173WI0130038) Health Insurance Plan, Variant (20173WI0130038-03) have Out of Service Area Coverage?
Does (20173WI0130038) Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for Asthma?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for Heart disease?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for Depression?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for Diabetes?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for Low back pain?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) offer Disease Management Programs for Pregnancy?
Does Robin Select $8,200 Limited Cost Sharing Bronze Health Insurance Plan, Variant (20173WI0130038-03) 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