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

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

 

In-Network Services

Local Deductible & Local Access Deductible Plan

Out-of-Network Services

Local Access Deductible Plan

Annual Medical Deductible

$500 individual / $1,000 family

When an individual within a family plan meets the $500 deductible, benefits apply as described below

Deductible applies to annual out-of-pocket limit (OOPL)

Prescriptions do not count toward your deductible

$1,000 individual / $2,000 family

When an individual within a family plan meets the $1,000 deductible, benefits apply as described below

Deductible applies to annual out-of-pocket limit (OOPL)

Prescriptions do not count toward your deductible

Annual Medical Coinsurance

100% until deductible met

After deductible, $0 except for durable medical equipment, adult hearing aids, and cochlear implants

After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL

Applies to medical services

Annual Medical Maximum
Out-of-Pocket Limit (OOPL)

$9,450 individual / $18,900 family for federally required essential health benefits

Only applies to durable medical equipment and emergency room copays

$4,000 individual / $8,000 family (includes deductible)

Routine, preventive services as required by federal law

$0

Plan pays 100%

For details, visit
healthcare.gov/preventive-care-benefits

After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL

Illness/injury-related services

After deductible, plan pays 100%

After deductible, plan pays 70%; you pay 30% coinsurance up 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

Deductible and coinsurance applies to services beyond the copay

You pay $60 copay, after copay in-network deductible and 30% coinsurance up to OOPL

Vision Exam

Routine exam: After deductible, plan pays 100% for one routine eye exam per year

Illness or injury: After deductible, plan pays 100% for adults or children

Routine exam: No benefit

Illness or injury: After deductible, plan pays 70% for adults or children; you pay 30% coinsurance up to OOPL

Hearing Exam

After deductible, plan pays 100%

After deductible, plan pays 70% only when exam is for illness or disease; you pay 30% coinsurance up to OOPL

Hearing Aid
(per ear)

Every 3 years:
Adults: After deductible, plan pays 80% up to $1,000 benefit limit; you pay 20% coinsurance for the first $1,000 and the full cost after

Children: After deductible, plan pays 100%

Every 3 years:
Adults: No benefit

Children: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL

Cochlear Implants

Adults: After deductible, you pay 20% coinsurance (not up to OOPL) for device, surgery, follow-up sessions; plan pays 100% for hospital charge for surgery

Dependents under age 18: Plan pays 100% for all services

Dependents under age 18: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL for device, surgery, follow-up sessions

Durable Medical Equipment

After deductible, plan pays 80%; you pay 20% coinsurance up to $500 OOPL per person

After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL

Physical/Speech/Occupational Therapy

After deductible, 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 70%; you pay 30% coinsurance up 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
(non-custodial care)

After deductible, plan pays 100% for 120 days per benefit period

After deductible, plan pays 70% for 120 days per benefit period; you pay 30% coinsurance up to OOPL

Home Health
(non-custodial care)

After deductible, plan pays 100% for 50 visits per year

Plan may approve an additional 50 visits

After deductible, plan pays 70%; you pay 30% 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: After deductible, plan pays 100%

Outpatient, inpatient, and covered transitional services: After deductible, plan pays 70%; you pay 30% coinsurance up to OOPL

Transplants

After deductible, plan pays 100%

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 the Local Deductible Plan, a referral is required for any benefits to be covered out-of-network

Not required

Oral Surgery

After deductible, plan pays 100%

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