Select Silver 5700 Ded/5700 MOOP HSA - 94529WI0210035 Health Insurance Plan
Group Health Cooperative of South Central Wisconsin health insurance plan with the Plan ID 94529WI0210035. The plan is called Select Silver 5700 Ded/5700 MOOP HSA.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.19% (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 29.81% 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 | 94529WI0210035 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 94529WI0210035-00 | ||||||||||||||||||
| Provider Network(s) | HMOSELECT | ||||||||||||||||||
| 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 - 94529WI0210035-00 Standard On Exchange Plan - 94529WI0210035-01 Open to Indians below 300% FPL - 94529WI0210035-02 Open to Indians above 300% FPL - 94529WI0210035-03 73% AV Silver Plan - 94529WI0210035-04 |
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| Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, 94529WI0210035-00
| 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
|
NO | ||
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Cardiac Rehabilitation
Limit: 36.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge after deductible |
100.00% |
| Emergency Room Services
Copay waived if admitted as a hospital inpatient. |
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 |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Generic Drugs
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years 1 Hearing Aid per ear per 36 months. |
YES | No Charge 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 after deductible |
100.00% |
| Hospice Services
|
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Post-Cochlear Implant Aural Rehabilitation Therapy
Limit: 30.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Pulmonary Rehabilitation Therapy
Limit: 20.0 Visit(s) per Year |
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. |
YES | No Charge 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 |
YES | No Charge after deductible |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
100.00% |
| Specialty Drugs
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Transplant
|
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan Variant 94529WI0210035-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.701861634291822 |
| 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 Silver Off Exchange Plan |
| 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 | Yes |
| 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 | Silver |
| 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) | 94529WI0210035-00 |
| 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 Silver 5700 Ded/5700 MOOP HSA |
| Plan Type | HMO |
| Plan Variant Marketing Name | Select Silver 5700 Ded/5700 MOOP HSA |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $5,700 |
| SBC Scenario, Having a Baby, Limit | $50 |
| SBC Scenario, Having Diabetes, Coinsurance | $120 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,290 |
| 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 | $2,170 |
| 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 | 94529WI0210035 |
| 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 | $11400 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5700 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,700 |
| 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 | $11400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $5700 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,700 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, 94529WI0210035
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Select Silver 5700 Ded/5700 MOOP HSA, 94529WI0210035 Health Insurance Plan, 94529WI0210035
-
Does Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, 94529WI0210035 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (94529WI0210035) Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs?
Does (94529WI0210035) Health Insurance Plan, Variant (94529WI0210035-00) have Out Of Country Coverage?
Does (94529WI0210035) Health Insurance Plan, Variant (94529WI0210035-00) have Out of Service Area Coverage?
Does (94529WI0210035) Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs?
Does Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs for Asthma?
Does Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs for Heart disease?
Does Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs for Diabetes?
Does Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Select Silver 5700 Ded/5700 MOOP HSA Health Insurance Plan, Variant (94529WI0210035-00) offer Disease Management Programs for Pregnancy?
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