Select Gold 2800 Ded/2800 MOOP HSA - 94529WI0210032 Health Insurance Plan
Group Health Cooperative of South Central Wisconsin health insurance plan with the Plan ID 94529WI0210032. The plan is called Select Gold 2800 Ded/2800 MOOP HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 | 94529WI0210032 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Group Health Cooperative of South Central Wisconsin | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 94529WI0210032-02 | ||||||||||||||||||
| Provider Network(s) | HMOSELECT | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 26 Nov 2024 06:27 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 94529WI0210032-00 Standard On Exchange Plan - 94529WI0210032-01 |
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| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 26 Nov 2024 06:27 GMT |
Benefits of Select Gold 2800 Ded/2800 MOOP HSA Health Insurance Plan, 94529WI0210032-02
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 0.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 0.00% |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | 0.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 0.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 0.00% |
100.00% |
| Dialysis
|
YES | 0.00% |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% |
100.00% |
| Emergency Room Services
Copay waived if admitted as a hospital inpatient. |
YES | 0.00% |
0.00% |
| Emergency Transportation/Ambulance
|
YES | 0.00% |
0.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 0.00% |
100.00% |
| Gender Affirming Care
Medically Necessary Gender Affirming Care is covered. GHC-SCW does not discriminate on the basis of sexual orientation or gender identity. |
YES | 0.00% |
100.00% |
| Generic Drugs
|
YES | 0.00% |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year 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. PT/OT Habilitative Therapies have a combined limit of 40 Visits per year. Habilitative Speech Therapy and Cognitive Therapy have a limit of 20 Visits per therapy per year. |
YES | 0.00% |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years 1 Hearing Aid per ear per 36 months. |
YES | 0.00% |
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 | 0.00% |
100.00% |
| Hospice Services
|
YES | 0.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 0.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 0.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 0.00% |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 0.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 0.00% |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 0.00% |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | 0.00% |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 0.00% |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 0.00% |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 0.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. PT/OT Rehabilitative Therapies have a combined limit of 40 Visits per year. Rehabilitative Speech Therapy, Pulmonary Rehabilition, and Cognitive Therapy have a limit of 20 Visits per therapy per year. Cardiac Rehabilitation Therapy has a limit of 36 Visits per year. Post-Cochlear Implant Aural Rehabilitation Therapy has a limit of 30 Visits per year. |
YES | 0.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% |
100.00% |
| Post-Cochlear Implant Aural Rehabilitation Therapy
Limit: 30.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Preferred Brand Drugs
|
YES | 0.00% |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | 0.00% |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 0.00% |
100.00% |
| Pulmonary Rehabilitation Therapy
Limit: 20.0 Visit(s) per Year |
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% |
100.00% |
| Reconstructive Surgery
|
YES | 0.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year PT/OT Rehabilitative Therapies have a combined limit of 40 Visits per year. |
YES | 0.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. |
YES | 0.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | 0.00% |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | 0.00% |
100.00% |
| Specialist Visit
|
YES | 0.00% |
100.00% |
| Specialty Drugs
|
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 0.00% |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 0.00% |
100.00% |
| Transplant
|
YES | 0.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 0.00% |
0.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 0.00% |
100.00% |
Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) Health Insurance Plan Variant 94529WI0210032-02 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 1.0 |
| 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 | Zero Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | WIF007 |
| Formulary URL | URL |
| HIOS Product ID | 94529WI021 |
| Import Date | 2023-12-19 01:01:03 |
| 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 | Yes |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 94529 |
| Issuer Marketplace Marketing Name | Group Health Cooperative-SCW |
| 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 | No |
| Out of Service Area Coverage | No |
| Plan Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 94529WI0210032-02 |
| Plan Level Exclusions | Prior Authorization, Medically Necessary/Medical Necessity, Act of War, Ongoing Medical Necessity, Experimental/ Investigational Treatment, Service Before Effective Date, Service After Termination Date, Services While Incarcerated, Any Charge for an Appointment a Member does not Attend, Services for Injuries Incurred During the Commission of a Crime |
| Plan Marketing Name | Select Gold 2800 Ded/2800 MOOP HSA |
| Plan Type | HMO |
| Plan Variant Marketing Name | Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $10 |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Specialist Requiring a Referral | Allergy, Asthma, Audiology, Cardiovascular, Dermatology, ENT/Otolaryngology, Endocrinology, Gastroenterology, General Surgery, Geriatrics, Hematology, Immunology, Infectious Diseases, Nephrology, Neurology , Neurosurgery, Medical Oncology, Ophthalmology, Orthopedics, Pain Management, Peripheral Vascular, Perinatology, Plastic Surgery, Pulmonology, Radiation Oncology, Rheumatology, Speech Therapy, Spine Medicine, Sports Medicine, Transplant Surgery/Medicine, Urology, Vascular Surgery, All out of area specialty care |
| Plan ID | 94529WI0210032 |
| 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 | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | $0 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $0 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $0 |
| 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 Select Gold 2800 Ded/2800 MOOP HSA Health Insurance Plan, 94529WI0210032
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select Gold 2800 Ded/2800 MOOP HSA, 94529WI0210032 Health Insurance Plan, 94529WI0210032
-
Does Select Gold 2800 Ded/2800 MOOP HSA Health Insurance Plan, 94529WI0210032 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94529WI0210032) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs?
Does (94529WI0210032) Health Insurance Plan, Variant (94529WI0210032-02) have Out Of Country Coverage?
Does (94529WI0210032) Health Insurance Plan, Variant (94529WI0210032-02) have Out of Service Area Coverage?
Does (94529WI0210032) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs?
Does Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs for Asthma?
Does Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs for Heart disease?
Does Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs for Diabetes?
Does Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Select Gold No Ded/0 MOOP Zero Cost Sharing (2800/2800) Health Insurance Plan, Variant (94529WI0210032-02) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 26 Nov 2024 06:27 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