The table below lists costs for common services for each plan design option. Your Certificate of Coverage details all of your benefits.

Regular out-of-network services are only available through the Local Access Health Plan. The Local Health Plan offers out-of-network services only for emergency or urgent care.
 

In-Network Services

Local Health Plan & Local Access Health Plan

Out-of-Network Services

Local Access Health Plan

Annual Medical Deductible

Individual / Family

Counts toward Out-of-Pocket Limit (OOPL)

$250 / $500

Office visit copays, preventive services, and prescription drugs do not count toward your deductible 

After an individual within a family plan meets the $250 deductible, benefits apply

$500 / $1,000

Prescription drugs do not count toward your deductible 

After an individual within a family plan meets the $500 deductible, benefits apply

 

Primary Care Office Visit

Additional services such as lab work, X-rays, etc. count toward the deductible and coinsurance

Includes:

  • Internist
  • General Physician
  • Family Practitioner
  • Pediatrician
  • Gynecologist / Obstetrician
  • Nurse Practitioner
  • Physician Assistant
  • Chiropractor
  • Physical / Occupational / Speech Therapy in an office visit setting

$15 copay per visit up to OOPL

Does not count toward deductible

After deductible, you pay 30% up to OOPL

Specialty Office Visit

Additional services such as lab work, X-rays, etc. count toward the deductible and coinsurance

Includes:

  • Specialty Providers
  • Urgent Care
  • Vision Exam in an office visit setting

$25 copay per visit up to OOPL

Does not count toward deductible

After deductible, you pay 30% up to OOPL

Annual Medical Coinsurance

Applies to medical services except for office visit or emergency room copayments and preventive services

100% until deductible met

After deductible, you pay 10% up to OOPL

100% until deductible met

After deductible, you pay 30% up to OOPL

Medical Out-of-Pocket Limit (OOPL)

Individual / Family

$1,250 / $2,500

$2,000 / $4,000

Preventive Services

See healthcare.gov/preventive-care-benefits

Plan pays 100%

Subject to the deductible and coinsurance
Illness/injury-related services beyond the office visit copayment (if applicable)

After deductible, you pay 10% up to OOPL

Applies to medical services except for office visit or emergency room copays

After deductible, you pay 30% up to OOPL

Applies to medical services except for emergency room copays

Emergency Room

Copay waived if admitted as an inpatient directly from the emergency room or for observation for 24 hours or longer

$75 copay per visit

Copay counts toward OOPL. Deductible and coinsurance apply to services beyond the copay

$75 copay per visit

Copay counts toward OOPL. Deductible and coinsurance may apply to services beyond the copay, up to OOPL

Transplants

After deductible, you pay 10% up to OOPL

After deductible, you pay 30% up to OOPL

Mental Health/Alcohol and Drug Abuse

Additional services such as lab work, assessments, etc. are subject to deductible and coinsurance

Outpatient services: $15 copay per visit

Inpatient & covered transitional services: After deductible, you pay 10% up to OOPL

Outpatient, inpatient, and covered transitional services: You pay 30% up to OOPL

Hearing Aid
(per ear)

Every three years:
Adults: After deductible, you pay 20% up to plan paid $1,000 (not to OOPL)

Dependents younger than age 18: After deductible, you pay 10% up to OOPL

Every three years: 
Adults: no benefit

For dependents younger than age 18: After deductible, you pay 30% up to OOPL

Cochlear Implants

Adults: After deductible, you pay 20% (not up to OOPL) for device, surgery for implantation, and follow-up sessions; for hospital charge for surgery you pay 10% up to OOPL

Dependents under age 18: After deductible, you pay 10% up to OOPL for all services

Dependents under age 18: After deductible, you pay 30% up to OOPL for device, surgery, and follow-up sessions

Skilled Nursing Facility
(non-custodial care)

After deductible, you pay 10% up to OOPL, 120 days per benefit period

After deductible, you pay 30% up to OOPL, 120 days per benefit period

Home Health
(non-custodial care)

After deductible, you pay 10% up to OOPL, 50 visits per plan year

Plan may approve an additional 50 visits

After deductible, you pay 30% up to OOPL, 50 visits per plan year

Plan may approve an additional 50 visits

Physical/Speech/Occupational Therapy

$15 copay for office visits

Additional services such as lab work, X-rays, etc. are subject to deductible and coinsurance up to OOPL

50 combined visits per plan year

Plan may approve an additional 50 combined visits per therapy type per year

After deductible, you pay 30% up to OOPL

50 combined visits per plan year

Plan may approve an additional 50 combined visits per therapy type per year

Durable Medical Equipment

After deductible, you pay 20% up to OOPL

After deductible, you pay 30% 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 Health Plan, a referral is required for any benefits to be covered out-of-network

Not required

Oral Surgery

After deductible, you pay 10% up to OOPL

After deductible, you pay 30% up to OOPL
Telemedicine Services Varies by service type. See etf.wi.gov/telemedicine  Varies by service type. See etf.wi.gov/telemedicine