HMO Bronze 6500 with 3 Free PCP visits

86584WI0010006
Expanded Bronze
HMO

HMO Bronze 6500 with 3 Free PCP visits is an Expanded Bronze HMO plan by Aspirus Health Plan.

IMPORTANT: You are viewing the 2023 version of HMO Bronze 6500 with 3 Free PCP visits 86584WI0010006. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

HMO Bronze 6500 with 3 Free PCP visits is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of HMO Bronze 6500 with 3 Free PCP visits 86584WI0010006.
Insurer: Aspirus Health Plan
Network Type: HMO
Metal Type: Expanded Bronze
HSA Eligible?: No
Plan ID: 86584WI0010006

Cost-Sharing Overview

HMO Bronze 6500 with 3 Free PCP visits offers the following cost-sharing.

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 6500 with 3 Free PCP visits?

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 6500 with 3 Free PCP visits offers the following features and referral requirements.

Wellness Program: No
Disease Program: Heart Disease, 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 6500 with 3 Free PCP visits 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 6500 with 3 Free PCP visits 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
20.00% Coinsurance after deductible 100.00% MH/SUD office visits are considered the same benefits as a primary care physician.
Specialist Visit
Covered
20.00% Coinsurance after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
20.00% Coinsurance after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
20.00% Coinsurance after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
20.00% Coinsurance after deductible 100.00%
Hospice Services
Covered
20.00% Coinsurance after deductible 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
20.00% Coinsurance after deductible 20.00% Coinsurance after deductible 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
20.00% Coinsurance after deductible 100.00%60 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
20.00% Coinsurance after deductible 20.00% Coinsurance after deductible Services provided by a non-participating provider will be paid at the participating provider level.
Emergency Transportation/Ambulance
Covered
20.00% Coinsurance after deductible 20.00% Coinsurance after deductible Services provided by a non-participating provider will be paid at the participating provider level.
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
20.00% Coinsurance after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
20.00% Coinsurance after deductible 100.00%
Bariatric Surgery
Not Covered
Cosmetic Surgery
Not Covered
Skilled Nursing Facility
Covered
20.00% Coinsurance after deductible 100.00%30 Days per Stay Coverage limited to 30 days per confinement.
Prenatal and Postnatal Care
Covered
20.00% Coinsurance after deductible 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
20.00% Coinsurance after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
20.00% Coinsurance after deductible 100.00% MH/SUD 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
20.00% Coinsurance after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
20.00% Coinsurance after deductible 100.00% MH/SUD 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
20.00% Coinsurance after deductible 100.00%
Generic Drugs
Covered
20.00% Coinsurance after deductible 100.00%30 Item(s) per Month See brochure for a listing of free preventive drugs.
Preferred Brand Drugs
Covered
20.00% Coinsurance after deductible 100.00%30 Item(s) per Month
Non-Preferred Brand Drugs
Covered
20.00% Coinsurance after deductible 100.00%30 Item(s) per Month
Specialty Drugs
Covered
20.00% Coinsurance after deductible 100.00%30 Item(s) per Month
Outpatient Rehabilitation Services
Covered
20.00% Coinsurance after deductible 100.00%20 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
20.00% Coinsurance after deductible 100.00%20 Visit(s) per Year No coverage for biofeedback. No coverage for biofeedback.
Chiropractic Care
Covered
20.00% Coinsurance after deductible 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
20.00% Coinsurance after deductible 100.00%1 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
20.00% Coinsurance after deductible 100.00%1 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.
Imaging (CT/PET Scans, MRIs)
Covered
20.00% Coinsurance after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00% No coverage for services provided by a non-participating provider.
Routine Foot Care
Not Covered
Coverage limited to services which are associated with a medical diagnosis of diabetes, peripheral vascular disease, or peripheral neuropathy.
Acupuncture
Not Covered
Weight Loss Programs
Not Covered
Routine Eye Exam for Children
Covered
No Charge 100.00% 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
No Charge 100.00%1 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
20.00% Coinsurance after deductible 100.00%20 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
20.00% Coinsurance after deductible 100.00%20 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
20.00% Coinsurance after deductible 100.00% No coverage for services provided by a non-participating provider.
Laboratory Outpatient and Professional Services
Covered
20.00% Coinsurance after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
20.00% Coinsurance after deductible 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
20.00% Coinsurance after deductible 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
20.00% Coinsurance after deductible 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
20.00% Coinsurance after deductible 100.00%
Allergy Testing
Covered
20.00% Coinsurance after deductible 100.00%
Chemotherapy
Covered
20.00% Coinsurance after deductible 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
20.00% Coinsurance after deductible 100.00%
Diabetes Education
Covered
20.00% Coinsurance after deductible 100.00%
Prosthetic Devices
Covered
20.00% Coinsurance after deductible 100.00%1 Item(s) per 3 Years Coverage limited to a single purchase of a type of prosthetic device every three years.
Infusion Therapy
Covered
20.00% Coinsurance after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
20.00% Coinsurance after deductible 100.00% No coverage for cosmetic or elective orthodontic care, periodontal care, or general dental care.
Nutritional Counseling
Covered
20.00% Coinsurance after deductible 100.00% No coverage for weight loss programs.
Reconstructive Surgery
Covered
20.00% Coinsurance after deductible 100.00% No coverage for reduction mammoplasty.
Gender Affirming Care
Clinical Trials
Covered
20.00% Coinsurance after deductible 100.00%
Diabetes Care Management
Covered
20.00% Coinsurance after deductible 100.00%
Dental Anesthesia
Covered
20.00% Coinsurance after deductible 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
20.00% Coinsurance after deductible 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.

Free Preventive Services

There is no copayment or coinsurance for any of the following HMO Bronze 6500 with 3 Free PCP visits 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.

Additional Resources

Below are additional resources for HMO Bronze 6500 with 3 Free PCP visits 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 6500 with 3 Free PCP visits?

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

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