The table below lists costs for common services for each It's Your Choice plan design option. Your Certificate of Coverage details all of your benefits.
|
|
In-Network Services Local HDHP & Local Access HDHP |
Out-Of-Network Services Local Access HDHP |
|---|---|---|
|
Annual Deductible Includes medical and prescription drugs |
$1,600 individual / $3,200 family The deductible must be met before coverage begins; for family coverage, the full family deductible must be met The deductible includes prescription drugs and applies to Out-of-Pocket-Limit (OOPL) |
$2,000 individual / $4,000 family The deductible must be met before coverage begins; for family coverage, the full family deductible must be met The deductible includes prescription drugs and applies to Out-of-Pocket-Limit (OOPL) |
|
Primary Care Provider (PCP) Office Visit Copay Includes:
|
You pay the full allowed amount of an office visit until deductible is met After deductible, you pay $15 copay per office visit up to OOPL Coinsurance will apply to additional services such as lab work, X-rays, etc. |
You pay the full allowed amount of an office visit until deductible is met After deductible, you pay 30% coinsurance up to OOPL |
|
Specialty Office Visit Copay Includes:
|
You pay the full allowed amount of an office visit until deductible is met After deductible, you pay $25 copay per office visit up to OOPL Coinsurance will apply to additional services such as lab work, X-rays, etc. |
You pay the full allowed amount of an office visit until deductible is met After deductible, you pay 30% coinsurance up to OOPL |
|
Annual Medical Coinsurance |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL Applies to medical services except for office visit or emergency room copays and preventive services |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL Applies to medical services except for emergency room copays |
|
Annual Out-of-Pocket Limit (OOPL) |
$2,500 individual / $5,000 family For family coverage, you must meet the full family OOPL before your plan pays 100% |
$3,800 individual / $7,600 family For family coverage, you must meet the full family OOPL before your plan pays 100% |
|
Routine, preventive services as required by federal law |
Plan pays 100% |
Subject to the deductible and coinsurance |
|
Illness/injury-related services beyond the office visit copayment (if applicable) |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL Applies to medical services except for office visit or emergency room copays |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL Applies to medical services except for emergency room copays |
|
Emergency Room Copayment Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer |
You pay the full allowed amount of services until deductible is met After deductible, you pay $75 copay per visit. Then coinsurance applies to services beyond the copay up to OOPL |
You pay the full allowed amount of services until deductible is met After deductible, you pay $75 copay per visit. Then in-network deductible and coinsurance apply to services beyond the copay up to OOPL |
|
Transplants |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
|
Mental Health/Alcohol & Drug Abuse |
Outpatient services: After deductible, you pay $15 copay for primary care office visits. Additional services such as lab work, assessments, etc. are subject to coinsurance Inpatient and covered transitional services: After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL All services apply to the annual OOPL |
Outpatient, inpatient, and covered transitional services: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
|
Hearing Aid |
You pay the full allowed amount of services until deductible is met Every 3 years: Dependents under age 18: After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL |
You pay the full allowed amount Every 3 years: |
|
Cochlear Implants |
You pay the full allowed amount of services until deductible is met Adults: After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL for device, surgery for implantation, and follow-up sessions For hospital charge for surgery: Dependents under age 18: After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL for all services |
You pay the full allowed amount Dependents under age 18: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL for device, surgery, and follow-up sessions |
|
Skilled Nursing Facility |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL 120 days per benefit period |
You pay the full allowed amount After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL 120 days per benefit period |
|
Home Health |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL 50 visits per plan year Plan may approve an additional 50 visits |
You pay the full allowed amount After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL 50 visits per plan year Plan may approve an additional 50 visits |
|
Physical/Speech/Occupational Therapy |
You pay the full allowed amount of services until deductible is met After deductible, you pay $15 copay for office visits. Additional services such as lab work, X-rays, etc. are subject to coinsurance up to OOPL 50 combined visits per plan year Plan may approve an additional 50 visits per therapy type per year |
You pay the full allowed amount After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL 50 combined visits per plan year Plan may approve an additional 50 visits per therapy type per year |
|
Durable Medical Equipment |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
|
Precertification for hospitalizations, high-tech radiology, and low back surgery |
Varies by plan. See plan descriptions and contact your plan |
Contact your plan |
|
Referrals |
In-network varies by plan. See plan descriptions and contact your plan For Local HDHP, a referral is required for any benefits to be covered out-of-network |
Not required |
|
Oral Surgery |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 90%; you pay 10% coinsurance up to OOPL |
You pay the full allowed amount of services until deductible is met After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL |
| Telemedicine Services | Varies by service type. See etf.wi.gov/telemedicine | Varies by service type. See etf.wi.gov/telemedicine |