SimplyOne $7,050 HDHP - 38166WI0300012 Health Insurance Plan
Security Health Plan of Wisconsin, Inc. health insurance plan with the Plan ID 38166WI0300012. The plan is called SimplyOne $7,050 HDHP.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 63.97% (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 36.03% 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 | 38166WI0300012 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Security Health Plan of Wisconsin, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 38166WI0300012-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Thu, 31 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of SimplyOne $7,050 HDHP Health Insurance Plan, 38166WI0300012-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Autism Spectrum Disorders
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| 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, No Charge after deductible |
100.00% |
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Chiropractic Care
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Clinical Trials
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Exclusions: Limitations include: prenatal cradle (maternity belt), home delivery and home visits, services performed by a licensed midwife or certified professional midwife, services to determine gender, abortion procedures to end a pregnancy except as specifically stated above. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Dental Anesthesia
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Care Management
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Dialysis
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Durable Medical Equipment
Exclusions: Limitations include: routine maintenance and replacement of equipment because of abuse and neglect and urable medical equipment and medical supplies for your comfort, personal hygiene, convenience or athletics-related conditions including, but not limited to, air conditioners, air cleaners, humidifiers, physical fitness equipment, disposable supplies, self-help devices not medical in nature, duplicate pieces of equipment, deluxe/nonstandard equipment and back-up equipment. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Emergency Room Services
Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home. |
YES | No Charge after deductible, No Charge after deductible |
No Charge after deductible, No Charge after deductible |
| Emergency Transportation/Ambulance
Exclusions: Limitations include: Ambulance transport to a home or outpatient setting, medical van transportation, non-emergency licensed professional ambulance services (unless authorized by Security Health Plan), first responders and rescue services and transportation from an acute facility to a sub-acute setting. |
YES | No Charge after deductible, No Charge after deductible |
No Charge after deductible, No Charge after deductible |
| Eye Glasses for Children
Limit: 1.0 Visit(s) per Year Exclusions: Limited to a selection of glasses approved by Security Health Plan |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Gender Affirming Care
Exclusions: Services covered only Hormone Therapy and Gender affirming services surgery |
NO | ||
| Generic Drugs
Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. 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. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | No Charge after deductible, 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, No Charge after deductible |
100.00% |
| Hospice Services
Exclusions: Limitations include: financial or legal counseling, including estate planning or drafting of a will, homemaker or caretaker services that are not solely related to the member?s care including, but not limited to, sitter or companion services for the member or the member?s family, transportation, house cleaning, or physical maintenance of the house and pastoral counseling or funeral arrangements. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | No Charge after deductible, 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, No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Mental Health Other
|
NO | ||
| Newborn Services Other
|
NO | ||
| Non-Preferred Brand Drugs
Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Nutritional Counseling
Exclusions: Covered only when both of the following are true: nutritional education is required for a disease in which patient self-management is an important component of the treatment and there exists a knowledge deficit regarding the disease which requires the intervention of a trained health professional |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 20.0 Visit(s) per Year Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. Rehabilitative services must be short term. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Preferred Brand Drugs
Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Prescription Drugs Other
|
NO | ||
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Exclusions: Limitations include: services that are not for or related to the treatment of an illness or injury, services that continue after the member reaches the expected state of improvement, resolution or stabilization of a health condition as determined by Security Health Plan, treatment provided by athletic trainers, physical therapy, speech therapy, occupational therapy and/or complementary therapy for the following conditions: learning disabilities, developmental delay (regardless of cause), perceptual disorders, intellectual disabilities or related conditions, behavior disorders, multiple handicaps, sensory deficit, motor dysfunction, communication or articulation disorders including apraxia, dyspraxia and pervasive development disorders. Rehabilitative services must be short term. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
YES | No Charge, No Charge after deductible |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge after deductible, No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay Exclusions: Limitations include: skilled nursing care and/or skilled therapy not prior approved by Security Health Plan and leave-of-absence days, respite care, custodial care, care exceeding the number of days shown in the member?s Schedule of Benefits. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Specialty Drugs
Exclusions: Limitations include: prescription drugs dispensed by non-network pharmacies, prescription drugs not found on the current version of the formulary, medications administered in a physician office (and/or associated fees) that could be safely self-administered or have oral or other alternatives that could be safely self-administered, prescription drugs as a replacement for a previously dispensed prescription drug that was lost, stolen, broken or destroyed, prescription drugs dispensed for an amount that exceeds the supply limit (daily supply or quantity limit), prescription drugs dispensed outside the United States, except as required for emergency treatment, prescription drugs packaged with an over-the-counter medication in a kit, unless the kit is specifically included on the current formulary. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Transplant
Exclusions: Limitations include: lodging expenses including meals, expenses related to the recipient?s transportation except for medically necessary professionally licensed ambulance services, the purchase price of any bone marrow, organ or tissue that is sold rather than donated, services not ordered by a physician or surgeon, transplants involving non-human or artificial organs or |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Limit: 4.0 Visit(s) per Year Exclusions: Limitations include: cosmetic or elective orthodontic care, periodontal care, general dental care, upper and lower jawbone surgery except as required for direct treatment of acute traumatic injury, dislocation, cancer or temporomandibular joint disorder and orthognathic surgery jaw alignment, except as a treatment of obstructive sleep apnea. |
YES | No Charge after deductible, No Charge after deductible |
100.00% |
| Urgent Care Centers or Facilities
Exclusions: Limitations include: care that can safely be postponed until the member returns to the service area, follow-up care received from a non-network provider unless prior authorized by Security Health Plan and take-home drugs and supplies dispensed by a hospital at the time of hospital discharge for use at home. |
YES | No Charge after deductible, No Charge after deductible |
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, No Charge after deductible |
100.00% |
SimplyOne $7,050 HDHP Health Insurance Plan Variant 38166WI0300012-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.6397370332054311 |
| 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, Weight Loss Programs |
| First Tier Utilization | 100% |
| Formulary ID | WIF006 |
| Formulary URL | URL |
| HIOS Product ID | 38166WI030 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2024-10-31 01:01:26 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 38166 |
| Issuer Marketplace Marketing Name | Security Health Plan |
| Market Coverage | SHOP (Small Group) |
| 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 | WIN007 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Urgent and Emergent Care |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Urgent and Emergent Care |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 38166WI0300012-00 |
| Plan Marketing Name | SimplyOne $7,050 HDHP |
| Plan Type | HMO |
| Plan Variant Marketing Name | SimplyOne $7,050 HDHP |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,050 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $5,400 |
| 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 | WIS007 |
| Source Name | HIOS |
| Plan ID | 38166WI0300012 |
| State Code | WI |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $7050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $7,050 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $14100 per group |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $7050 per person |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $7,050 |
| 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 | $14100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7050 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,050 |
| 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 | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
| 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 | Yes |
Copay & Coinsurance of SimplyOne $7,050 HDHP Health Insurance Plan, 38166WI0300012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SimplyOne $7,050 HDHP, 38166WI0300012 Health Insurance Plan, 38166WI0300012
-
Does SimplyOne $7,050 HDHP Health Insurance Plan, 38166WI0300012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (38166WI0300012) Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs?
Does (38166WI0300012) Health Insurance Plan, Variant (38166WI0300012-00) have Out Of Country Coverage?
Does (38166WI0300012) Health Insurance Plan, Variant (38166WI0300012-00) have Out of Service Area Coverage?
Does (38166WI0300012) Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs?
Does SimplyOne $7,050 HDHP Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs for Asthma?
Does SimplyOne $7,050 HDHP Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs for Heart disease?
Does SimplyOne $7,050 HDHP Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs for Depression?
Does SimplyOne $7,050 HDHP Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs for Diabetes?
Does SimplyOne $7,050 HDHP Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs for Pregnancy?
Does SimplyOne $7,050 HDHP Health Insurance Plan, Variant (38166WI0300012-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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