Select Silver 5400 Ded/5400 MOOP HSA

94529WI0210035
Silver
HMO

Select Silver 5400 Ded/5400 MOOP HSA is a Silver HMO plan by Group Health Cooperative-SCW.

IMPORTANT: You are viewing the 2023 version of Select Silver 5400 Ded/5400 MOOP HSA 94529WI0210035. You can enroll in this plan if you qualify for special enrollment until the end of 2023.

Locations

Select Silver 5400 Ded/5400 MOOP HSA is offered in the following counties.

Plan Overview

This is a plan overview for 2023 version of Select Silver 5400 Ded/5400 MOOP HSA 94529WI0210035.
Insurer: Group Health Cooperative-SCW
Network Type: HMO
Metal Type: Silver
HSA Eligible?: Yes
Plan ID: 94529WI0210035

Cost-Sharing Overview

Select Silver 5400 Ded/5400 MOOP HSA 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 Select Silver 5400 Ded/5400 MOOP HSA?

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

Select Silver 5400 Ded/5400 MOOP HSA offers the following features and referral requirements.

Wellness Program: No
Disease Program: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
Notice Pregnancy: Yes
Referral Specialist: Yes
Specialist Requiring Referral: Allergy, Asthma, Audiology, Cardiovascular, Dermatology, ENT/Otolaryngology, Endocrinology, Gastroenterology, General Surgery, Geriatrics, Hematology, Immunology, Infectious Diseases, Nephrology, Neurology , Neurosurgery, Medical Oncology, Ophthalmology, Orthopedics, Pain Management, Peripheral Vascular, Perinatology, Plastic Surgery, Pulmonology, Radiation Oncology, Rheumatology, Speech Therapy, Spine Medicine, Sports Medicine, Transplant Surgery/Medicine, Urology, Vascular Surgery, All out of area specialty care
Plan Exclusions: Prior Authorization, Medically Necessary/Medical Necessity, Act of War, Ongoing Medical Necessity, Experimental/ Investigational Treatment, Service Before Effective Date, Service After Termination Date, Services While Incarcerated, Any Charge for an Appointment a Member does not Attend, Services for Injuries Incurred During the Commission of a Crime
Child Only Option?: Allows Adult and Child-Only

Network Details

The following network details will help you understand what Select Silver 5400 Ded/5400 MOOP HSA covers when you are out of the service area or out of the country.

Out of Country Coverage: No
Out of Country Coverage Description:
Out of Service Area Coverage: No
Out of Service Area Coverage Description:
National Network: No

Additional Benefits and Cost-Sharing

Select Silver 5400 Ded/5400 MOOP HSA 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
No Charge after deductible 100.00%
Specialist Visit
Covered
No Charge after deductible 100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
No Charge after deductible 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
No Charge after deductible 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
No Charge after deductible 100.00%
Hospice Services
Covered
No Charge after deductible 100.00%
Routine Dental Services (Adult)
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
No Charge after deductible No Charge after deductible
Home Health Care Services
Covered
No Charge 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
No Charge after deductible No Charge after deductible Copay waived if admitted as a hospital inpatient.
Emergency Transportation/Ambulance
Covered
No Charge after deductible No Charge after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
No Charge after deductible 100.00%
Inpatient Physician and Surgical Services
Covered
No Charge after deductible 100.00%
Bariatric Surgery
Cosmetic Surgery
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%30 Days per Stay
Prenatal and Postnatal Care
Covered
No Charge 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Outpatient Services
Covered
No Charge after deductible 100.00%
Mental/Behavioral Health Inpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Outpatient Services
Covered
No Charge after deductible 100.00%
Substance Abuse Disorder Inpatient Services
Covered
No Charge after deductible 100.00%
Generic Drugs
Covered
No Charge after deductible 100.00%
Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Non-Preferred Brand Drugs
Covered
No Charge after deductible 100.00%
Specialty Drugs
Covered
No Charge after deductible 100.00%
Outpatient Rehabilitation Services
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Rehabilitative services must be short term. PT/OT Rehabilitative Therapies have a combined limit of 40 Visits per year. Rehabilitative Speech Therapy, Pulmonary Rehabilition, and Cognitive Therapy have a limit of 20 Visits per therapy per year. Cardiac Rehabilitation Therapy has a limit of 36 Visits per year. Post-Cochlear Implant Aural Rehabilitation Therapy has a limit of 30 Visits per year.
Habilitation Services
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. PT/OT Habilitative Therapies have a combined limit of 40 Visits per year. Habilitative Speech Therapy and Cognitive Therapy have a limit of 20 Visits per therapy per year.
Chiropractic Care
Covered
No Charge after deductible 100.00% Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.
Durable Medical Equipment
Covered
No Charge after deductible 100.00%
Hearing Aids
Covered
No Charge after deductible 100.00%1 Item(s) per 3 Years 1 Hearing Aid per ear per 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
No Charge 100.00%
Routine Foot Care
Acupuncture
Weight Loss Programs
Routine Eye Exam for Children
Covered
No Charge after deductible 100.00%1 Exam(s) per Year
Eye Glasses for Children
Covered
No Charge after deductible 100.00%1 Item(s) per Year
Dental Check-Up for Children
Not Covered
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Year Rehabilitative services must be short term.
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%40 Visit(s) per Year PT/OT Rehabilitative Therapies have a combined limit of 40 Visits per year.
Well Baby Visits and Care
Covered
No Charge 100.00%
Laboratory Outpatient and Professional Services
Covered
No Charge after deductible 100.00%
X-rays and Diagnostic Imaging
Covered
No Charge after deductible 100.00%
Basic Dental Care – Child
Not Covered
Orthodontia – Child
Not Covered
Major Dental Care – Child
Not Covered
Basic Dental Care – Adult
Orthodontia – Adult
Major Dental Care – Adult
Abortion for Which Public Funding is Prohibited
Not Covered
Transplant
Covered
No Charge after deductible 100.00%
Accidental Dental
Covered
No Charge after deductible 100.00%
Dialysis
Covered
No Charge after deductible 100.00%
Allergy Testing
Chemotherapy
Covered
No Charge after deductible 100.00% Intravenous chemotherapy is covered.
Radiation
Covered
No Charge after deductible 100.00%
Diabetes Education
Covered
No Charge after deductible 100.00%
Prosthetic Devices
Covered
No Charge after deductible 100.00%
Infusion Therapy
Covered
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 100.00%
Nutritional Counseling
Reconstructive Surgery
Covered
No Charge after deductible 100.00%
Gender Affirming Care
Covered
No Charge after deductible 100.00% Medically Necessary Gender Affirming Care is covered. GHC-SCW does not discriminate on the basis of sexual orientation or gender identity.
Cardiac Rehabilitation
Covered
No Charge after deductible 100.00%36 Visit(s) per Year
Post-Cochlear Implant Aural Rehabilitation Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Year
Pulmonary Rehabilitation Therapy
Covered
No Charge after deductible 100.00%20 Visit(s) per Year

Free Preventive Services

There is no copayment or coinsurance for any of the following Select Silver 5400 Ded/5400 MOOP HSA 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 Select Silver 5400 Ded/5400 MOOP HSA 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 Select Silver 5400 Ded/5400 MOOP HSA?

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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