Envision - Silver 4000/75 Plan Details for 2020- HealthPocket

Envision - Silver 4000/75

$502.80/mo

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Zip Code53215
Applicant4/6/1985 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameEnvision - Silver 4000/75
Plan IDhhs-87416WI0030021
Plan Year2020
Insurance ProviderCGHC
Metal LevelSilver
Plan TypeEPO
Deductible$4,000
Out-of-Pocket Maximum$8,150
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$50 Copay
Specialist Visit$80 Copay
Laboratory Outpatient and Professional Services25.00% Coinsurance after deductible
X-rays and Diagnostic Imaging25.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans25.00% Coinsurance after deductible
Deductible - Family$8000 per group
Out-of-Pocket Maximum - Family$16300 per group

Prescription drug coverage

Generic Drugs$20 Copay
Preferred Brand Drugs$75 Copay after deductible
Non-Preferred Brand Drugs25.00% Coinsurance after deductible
Specialty Drugs30.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://portal.commongroundhealthcare.org/Router.jsp?component=Main&source=Logon&action=ProviderDirectory
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?No - Emergency Services Only
Does this plan cover services outside the country?Yes - Emergency Services Only

Hospital services

Emergency Room Services25.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)25.00% Coinsurance after deductible
Inpatient Physician and Surgical Services25.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service25.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care25.00% Coinsurance after deductible
Delivery and all inpatient services for maternity care25.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$50 Copay
Mental/Behavioral Health Inpatient Services25.00% Coinsurance after deductible
Substance use disorder outpatient services$50 Copay
Substance use disorder inpatient services25.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsNot Covered

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareNot Covered
Adult Dental Coverage - Basic Dental CareNot Covered
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Hearing Aids
Imaging (CT/PET Scans, MRIs)
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Outpatient Rehabilitation Services
Durable Medical Equipment
Hospice Services
Chiropractic Care
Accidental Dental
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
More Limited BenefitsSkilled Nursing Facility
Home Health Care Services
Habilitation Services
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Routine Foot Care
Abortion for Which Public Funding is Prohibited
Allergy Testing
Nutritional Counseling
PremiumPlan NameDeductible
from $267
Select Bronze 4000 Ded/7350 MOOP
$4,000.00Select
from $291
Dean Focus Network Silver HSA-E 4050
$4,050.00Select
from $308
Bronze 4000 Ded/7350 MOOP
$4,000.00Select
from $309
Dean Silver HSA-E 4050
$4,050.00Select
from $310
Dean Focus Network Silver HSA-E 4000X
$4,000.00Select
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  • Phone Number
    (414) 672-8550
  • Office Locations
    2901 W Kinnickinnic River Pkwy
    Milwaukee, WI 53215
2901 W Kinnickinnic River Pkwy Milwaukee WI, 53215
  • What Is the Silver Plan?

    ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.

  • How are Silver Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.

  • How much does a Silver Plan cost?

    The monthly premium for a Silver Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Silver Plan premiums in your area.

  • When Can I Enroll in a Silver Plan?

    The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, or an individual and family health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is part of the Health Insurance Innovations, Inc. family of companies (NASDAQ: HIIQ).