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.

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

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 Out-of-Pocket Limit (OOPL)

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

None

Routine, preventive services as required by federal law

Plan pays 100%

For details, visit
healthcare.gov

After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL

Illness/injury related services

Plan pays 100%

After deductible, plan pays 80%; you pay 20% 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

You pay $60 copay; the in-network deductible applies to services after the copay

Vision Exam

Routine exam: Plan pays 100% (one per year)

Illness or injury exam: Plan pays 100%

Routine exam: No benefit

Illness or injury exam: After deductible, plan pays 80% for adults or children; you pay 20% coinsurance up to OOPL

Hearing Exam

Plan pays 100%

After deductible, plan pays 80% only when exam is for illness or disease; you pay 20% coinsurance up to OOPL

Hearing Aid
(per ear, every 3 years)

Adults: Plan pays 80% up to $1,000 benefit limit; you pay 20% coinsurance for the first $1,000 and the full cost after

Children: Plan pays 100%

Adults: No benefit

Children: After deductible, plan pays 80%; you pay 20% coinsurance up to OOPL

Cochlear Implants

Adults: Plan pays 80%; you pay 20% coinsurance (not up to OOPL) for device, surgery, and 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 80%; you pay 20% coinsurance up to OOPL for device, surgery, and 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 up 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 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)

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
(non-custodial care)

Plan pays 100% for 50 visits per year

Plan may approve an additional 50 visits

After deductible, plan pays 80%; 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

Contact your plan

Referrals

In-network: Varies by plan. See plan descriptions and contact your plan

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

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