Wellmark Gold Traditional HMO - 25896IA0370006 Health Insurance Plan
Wellmark Health Plan of Iowa, Inc. health insurance plan with the Plan ID 25896IA0370006. The plan is called Wellmark Gold Traditional HMO.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.97% (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 21.03% 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 | 25896IA0370006 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Iowa | ||||||||||||||||||
| Health Insurance Issuer | Wellmark Health Plan of Iowa, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 25896IA0370006-03 | ||||||||||||||||||
| Provider Network(s) | WELLMARK-BLUE-HMO-NETWORK | ||||||||||||||||||
| 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 - 25896IA0370006-00 Standard On Exchange Plan - 25896IA0370006-01 |
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| Last Plan Update Date | Thu, 10 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Wellmark Gold Traditional HMO Health Insurance Plan, 25896IA0370006-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Care must be completed within 12 months |
YES | $45.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
Allergy testing is a covered benefit |
YES | $45.00 |
100.00% |
| Bariatric Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Pediatric dental not embedded |
NO | ||
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | $30.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Pediatric dental not embedded |
NO | ||
| Diabetes Education
|
YES | $30.00 |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $400.00 |
$400.00 |
| 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 |
YES | 80.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | $20.00 |
100.00% |
| Habilitation Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
Quantitative limits apply, see EHB benchmark. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
YES | $30.00 |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Pediatric dental not embedded |
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| 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 documents for detailed information. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $125.00 |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Pediatric dental not embedded |
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $60.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Quantitative limits apply, see EHB benchmark. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $15.00 |
100.00% |
| Private-Duty Nursing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Prosthetic devices are covered |
YES | 20.00% |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
No limit on covered benefit |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $45.00 |
100.00% |
| Specialty Drugs
|
YES | $300.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $30.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Covered for child through age 7. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan Variant 25896IA0370006-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7896732851584358 |
| 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 | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | IAF001 |
| Formulary URL | URL |
| HIOS Product ID | 25896IA037 |
| Import Date | 2024-10-10 20:01:47 |
| 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 | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 25896 |
| Issuer Marketplace Marketing Name | Wellmark Health Plan of Iowa, Inc. |
| 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 | IAN001 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Accidental injury and emergency services only |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Accidental injury and emergency services only |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 25896IA0370006-03 |
| Plan Marketing Name | Wellmark Gold Traditional HMO |
| Plan Type | HMO |
| Plan Variant Marketing Name | Wellmark Gold Traditional HMO - Ltd AI/AN |
| 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 | $60 |
| 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 | $0 |
| Service Area ID | IAS001 |
| Source Name | SERFF |
| Plan ID | 25896IA0370006 |
| State Code | IA |
| 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 | 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 | $15200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,600 |
| 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 Summary of Benefits & Coverage | URL |
| Wellness Program Offered | Yes |
Copay & Coinsurance of Wellmark Gold Traditional HMO Health Insurance Plan, 25896IA0370006
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Wellmark Gold Traditional HMO, 25896IA0370006 Health Insurance Plan, 25896IA0370006
-
Does Wellmark Gold Traditional HMO Health Insurance Plan, 25896IA0370006 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (25896IA0370006) Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs?
Does (25896IA0370006) Health Insurance Plan, Variant (25896IA0370006-03) have Out Of Country Coverage?
Does (25896IA0370006) Health Insurance Plan, Variant (25896IA0370006-03) have Out of Service Area Coverage?
Does (25896IA0370006) Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Asthma?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Heart disease?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Depression?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Diabetes?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Low back pain?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Pregnancy?
Does Wellmark Gold Traditional HMO - Ltd AI/AN Health Insurance Plan, Variant (25896IA0370006-03) offer Disease Management Programs for Weight loss programs?
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