HMO Bronze $0 Medical Deductible
86584WI0010016
Expanded Bronze
HMO
HMO Bronze $0 Medical Deductible is an Expanded Bronze HMO plan by Aspirus Health Plan.
Locations
HMO Bronze $0 Medical Deductible is offered in the following counties.
Plan Overview
This is a plan overview for 2025 version of HMO Bronze $0 Medical Deductible 86584WI0010016.
| Insurer: | Aspirus Health Plan |
| Network Type: | HMO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | No |
| Plan ID: | 86584WI0010016 |
Cost-Sharing Overview
HMO Bronze $0 Medical Deductible offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for HMO Bronze $0 Medical Deductible includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9200 per person | $18400 per group |
| Deductible: | $0 per person | $0 per group |
| Coinsurance: | $0 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for HMO Bronze $0 Medical Deductible will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $0 |
| Copayment: | $1,500 |
| Coinsurance: | $2,800 |
| Limit: | $60 |
| Deductible: | $0 |
| Copayment: | $1,100 |
| Coinsurance: | $500 |
| Limit: | $20 |
| Deductible: | $0 |
| Copayment: | $1,000 |
| Coinsurance: | $900 |
| Limit: | $0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for HMO Bronze $0 Medical Deductible?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
HMO Bronze $0 Medical Deductible offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Diabetes, High Blood Pressure & High Cholesterol |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what HMO Bronze $0 Medical Deductible covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | Limited to emergency care only |
| Out of Service Area Coverage: | No |
| Out of Service Area Coverage Description: | Limited to emergency care only |
| National Network: | No |
Additional Benefits and Cost-Sharing
HMO Bronze $0 Medical Deductible includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $35.00 Not Applicable | Not Applicable 100.00% | MH/SUD/telehealth office visits are considered the same benefits as a primary care physician. Catastrophic plan includes 3 free visits, see summary of benefits for additional details. |
| Specialist Visit Covered | $200.00 Not Applicable | Not Applicable 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $35.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | $200.00 Not Applicable | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | $200.00 Not Applicable | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Routine Dental Services (Adult) Not Covered | |||
| Infertility Treatment Not Covered | |||
| Long-Term/Custodial Nursing Home Care Not Covered | |||
| Private-Duty Nursing Not Covered | |||
| Routine Eye Exam (Adult) Not Covered | |||
| Urgent Care Centers or Facilities Covered | $200.00 Not Applicable | $200.00 Not Applicable | Services provided by a non-participating provider will be paid at the participating provider level if for emergency medical care. |
| Home Health Care Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | 60.0 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. |
| Emergency Room Services Covered | $3,000.00 Not Applicable | $3,000.00 Not Applicable | Services provided by a non-participating provider will be paid at the participating provider level. |
| Emergency Transportation/Ambulance Covered | Not Applicable 50.00% | Not Applicable 50.00% | Services provided by a non-participating provider will be paid at the participating provider level. |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | $1500.00 Copay per Day Not Applicable | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Bariatric Surgery Not Covered | |||
| Cosmetic Surgery Not Covered | |||
| Skilled Nursing Facility Covered | $1500.00 Copay per Day Not Applicable | Not Applicable 100.00% | 30.0 Days per Stay Coverage limited to 30 days per confinement. |
| Prenatal and Postnatal Care Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Mental/Behavioral Health Outpatient Services Covered | $35.00 Not Applicable | Not Applicable 100.00% | MH/SUD/telehealth office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance. |
| Mental/Behavioral Health Inpatient Services Covered | $1500.00 Copay per Day Not Applicable | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $35.00 Not Applicable | Not Applicable 100.00% | MH/SUD/telehealth office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance. |
| Substance Abuse Disorder Inpatient Services Covered | $1500.00 Copay per Day Not Applicable | Not Applicable 100.00% | |
| Generic Drugs Covered | $35.00 Not Applicable | Not Applicable 100.00% | 30.0 Item(s) per Month See brochure for a listing of free preventive drugs. |
| Preferred Brand Drugs Covered | $125.00 Not Applicable | Not Applicable 100.00% | 30.0 Item(s) per Month |
| Non-Preferred Brand Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Item(s) per Month |
| Specialty Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 30.0 Item(s) per Month |
| Outpatient Rehabilitation Services Covered | $200.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year No coverage for vocational or industrial rehabilitation including work hardening programs; cardiac rehabilitation beyond Phase II; sports hardening and rehabilitation; services by a personal trainer; long-term or maintenance therapy. Coverage is limited to 20 visits per year for pulmonary rehabilitation; 36 visits per year for cardiac rehabilitation; 30 visits per year for post-cochlear implant aural therpy; 20 visits for cognitive rehabilitation therapy. 20 visit limit for PT, OT and ST. |
| Habilitation Services Covered | $35.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year No coverage for biofeedback. Visit limit applies only to Physical Thearpy |
| Chiropractic Care Covered | $35.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
| Durable Medical Equipment Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1.0 Item(s) per 3 Years No coverage for rental fees greater than the purchase price, continuous passive motion (CPM) devices, mechanical stretching devices, home spinal traction devices or standers, home INR (international normalized ration blood test) monitors, home phototherapy for dermatological conditions, cold therapy, cryotherapy, home automated external defibrillator (AED), DME with special features that are not medically necessary, DME for your comfort, personal hygiene, or convenience, self-help devices not medical in nature, Routine periodic maintenance, replacement of DME unless medically necessary, replacement of over-the-counter batteries, repairs due to abuse or misuse, light boxes designed for Seasonal Affective Disorder, devices and computers to assist in communication and speech except for speech aid devices and tracheo-esophageal voice devices, blood pressure cuffs and monitors, enuresis alarms, trusses, ultrasonic nebulizers, oral appliances for snoring. Coverage is limited to a single purchase of a type of DME every 3 years. Coverage is limited to one of the following: a manual wheelchair, a motorized wheelchair, a knee walker, or a motorized scooter. Coverage is limited to one insulin infusion pump per year. |
| Hearing Aids Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1.0 Item(s) per 3 Years No coverage for batteries and cords; or hearing protection equipment. Coverage is limited to one hearing aid per ear every three years. Coverage is limited to a single purchase (including repair/replacement) every three years for adults. No coverage for over the counter hearing devices. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable No Charge | Not Applicable 100.00% | No coverage for services provided by a non-participating provider. |
| Routine Foot Care | Coverage limited to services which are associated with a medical diagnosis of diabetes, peripheral vascular disease, or peripheral neuropathy. | ||
| Acupuncture | |||
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Exam(s) per Year Coverage is limited to children through the last day of the calendar month of their 19th birthday; no coverage for services by a non-participating provider.” |
| Eye Glasses for Children Covered | Not Applicable No Charge | Not Applicable 100.00% | 1.0 Item(s) per Year No coverage for services provided by a non-participating provider. Contact lenses covered in lieu of all other frames and/or lenses. Coverage is limited to one pair of eyeglasses (frames and lenses) per year. |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $200.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year No coverage for long-term and maintenance thearpy. Coverage is limited to 20 visits per year. |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $200.00 Not Applicable | Not Applicable 100.00% | 20.0 Visit(s) per Year No coverage for therapy for attention deficit disorder, hyperactivity disorder, sensory defensiveness, mental retardation, and related conditions; biofeedback; long-term and maintenance therapy. Coverage is limited to 20 visits per year for physical thearpy and 20 visits per year for occupational thearpy. |
| Well Baby Visits and Care Covered | Not Applicable No Charge | Not Applicable 100.00% | No coverage for services provided by a non-participating provider. |
| Laboratory Outpatient and Professional Services Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult Not Covered | |||
| Orthodontia – Adult Not Covered | |||
| Major Dental Care – Adult Not Covered | |||
| Abortion for Which Public Funding is Prohibited Not Covered | |||
| Transplant Covered | Not Applicable 50.00% | Not Applicable 100.00% | No coverage for transplants that are not listed as approved transplant services; expenses related to purchase of any organ;services provided by a non-participating provider. |
| Accidental Dental Covered | Not Applicable 50.00% | Not Applicable 100.00% | No coverage for injuries or damage to teeth, natural or otherwise, as a result of or caused by chewing food or similar substances. Care must start within 3 months and be completed within 12 months of the injury. |
| Dialysis Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Allergy Testing Covered | $200.00 Not Applicable | Not Applicable 100.00% | |
| Chemotherapy Covered | $200.00 Not Applicable | Not Applicable 100.00% | Intravenous chemotherapy is covered. |
| Radiation Covered | $200.00 Not Applicable | Not Applicable 100.00% | |
| Diabetes Education Covered | Not Applicable No Charge | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 50.00% | Not Applicable 100.00% | 1.0 Item(s) per 3 Years Coverage limited to a single purchase of a type of prosthetic device every three years. |
| Infusion Therapy Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 50.00% | Not Applicable 100.00% | No coverage for cosmetic or elective orthodontic care, periodontal care, or general dental care. |
| Nutritional Counseling | No coverage for weight loss programs. | ||
| Reconstructive Surgery Covered | Not Applicable No Charge | Not Applicable 100.00% | No coverage for reduction mammoplasty. |
| Gender Affirming Care Covered | Not Applicable 50.00% | Not Applicable 100.00% | When Medically necessary |
| Clinical Trials Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Diabetes Care Management Covered | Not Applicable 50.00% | Not Applicable 100.00% | |
| Dental Anesthesia Covered | Not Applicable 50.00% | Not Applicable 100.00% | Coverage limited to children under age 5 or individuals with a chronic disability or medical condition that requires hospitalization or general anesthesia for dental care. |
| Autism Spectrum Disorders Covered | Not Applicable 50.00% | Not Applicable 100.00% | Up to four years of intensive-level services that commence after you are two years of age and before you are nine years of age. |
| Virtual Care Covered | $20.00 Not Applicable | Not Applicable 100.00% | Benefit exclusive to using MDLIVE service |
Free Preventive Services
There is no copayment or coinsurance for any of the following HMO Bronze $0 Medical Deductible preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for HMO Bronze $0 Medical Deductible including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for HMO Bronze $0 Medical Deductible?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904