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 Traditional & Local Access Plan |
Out-of-Network Services Local Access Plan |
|
|---|---|---|
|
Annual Medical Deductible |
No deductible |
$500 individual / $1,000 family When an individual within a family plan meets the $500 deductible, coinsurance will apply to covered medical services Medical deductible does not apply to prescription drugs |
|
Annual Medical Coinsurance |
None Plan pays 100% for most services Exceptions: durable medical equipment, adult hearing aids and cochlear implants |
After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL |
|
Annual Medical Maximum Out-of-Pocket Limit (OOPL) |
$8,700 individual / $17,400 family for federally required essential health benefits Only applies to durable medical equipment and emergency room copays |
None |
|
Routine, preventive services as required by federal law |
Plan pays 100% For details, visit |
After deductible plan pays 80%, you pay 20% coinsurance to OOPL |
|
Illness/injury related services |
Plan pays 100% |
After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL |
|
Emergency Room Copay (Waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer.) |
You pay $60 copay per visit |
You pay $75 copay, the in-network deductible applies to services after the copay |
|
Vision Exam |
Plan pays 100% for one routine exam per year; plan pays 100% for exams related to illness or injury |
Routine exam: No benefit Illness or injury: After deductible plan pays 80% for adults or children; you pay 20% coinsurance to OOPL |
|
Hearing Exam |
Plan pays 100% |
After deductible: Plan pays 80% only when exam is for illness or disease; you pay 20% coinsurance to OOPL |
|
Hearing Aid |
Adults: Plan pays 80% up to $1,000 benefit limit, you pay 20% coinsurance for the first $1,000 and the full cost after |
Adults: No benefit Children: After deductible, plan pays 80%; you pay 20% coinsurance to OOPL |
|
Cochlear Implants |
Adults: Plan pays 80%, you pay 20% coinsurance for device, surgery, follow-up sessions (not to OOPL); plan pays 100% for hospital charge for surgery Dependents under 18, plan pays 100% for all services |
Dependents under 18, After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for device, surgery, follow-up sessions |
|
Durable Medical Equipment |
Plan pays 80%, you pay 20% coinsurance up to $500 OOPL per person |
After deductible: Plan pays 80%, you pay 20% coinsurance to OOPL |
|
Physical/Speech/Occupational Therapy |
Plan pays 100% for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year |
After deductible: Plan pays 80% you pay 20% coinsurance to OOPL for a combined 50 visits per year (amongst all therapies); plan may approve an additional 50 visits per therapy type per year |
|
Skilled Nursing Facility |
Plan pays 100% for 120 days per benefit period |
After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL for 120 days per benefit period |
|
Home Health |
Plan pays 100% for 50 visits per year Plan may approve an additional 50 visits |
After deductible: Plan pays 80% and you pay 20% coinsurance up to OOPL for 50 visits per plan year Plan may approve an additional 50 visits |
|
Mental Health/Alcohol & Drug Abuse |
Outpatient, inpatient and covered transitional services. Plan pays 100% |
Outpatient, inpatient and covered transitional services. After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL |
|
Transplants |
Plan pays 100% |
After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL |
|
Precertification for hospitalizations, high-tech radiology and low back surgery |
Varies by plan See plan descriptions and contact your plan |
Varies by plan See plan descriptions and contact your plan |
|
Referrals |
In-network varies by plan See plan descriptions and contact your plan Out-of-network: Referral is required |
Not required |
|
Oral Surgery |
Plan pays 100% |
After deductible: Plan pays 80%, you pay 20% coinsurance up to OOPL |
| Telemedicine Services | Varies by service type, see etf.wi.gov/telemedicine | Varies by service type, see etf.wi.gov/telemedicine |