OTHER IMPORTANT INFORMATION Eligibility and Requirements
Deductible and Out-Of-Pocket Maximum Details The deductible and out-of-pocket maximum are subject to a “cost of living” increase on a yearly basis. This increase is tied to the Consumer Price Index and/or may result from adjustments needed to keep plans within the range for a given metal level; metal levels (e.g., Gold, Silver, Bronze) must always be in compliance with the Affordable Care Act (ACA) for Qualified Health Plans (QHPs). The Marketplace and Cost Share Reduction Plans You may be able to receive help paying your health insurance premium or qualify for plans with reduced deductibles and copays. Plans with reduced deductibles and copays are called Cost Share Reduction (CSR) plans. You can get this assistance if you get health insurance through the Health Insurance Marketplace, your income is below a certain level, and you choose a health plan from the Silver plan category. Reduced cost sharing is not available with a Catastrophic plan. If you’re a member of a federally recognized tribe, you may qualify for additional cost-sharing benefits. To see if you’re eligible, please visit healthcare.gov . Receiving Care Outside Your Network Unless it's an emergency, there is no coverage if you visit a provider that is not in your network. This means you'll be responsible for the full cost of any care or supplies. Emergency care received from an out-of-network provider may result in balance billing from that provider. Please see a policy on Medica.com/Plans4WI for details. Medica Privacy Notice Medica takes its responsibility of protecting your personal information seriously. Where possible, Medica de-identifies or encrypts personal information. We use and disclose personal information only to the extent necessary to conduct treatment, payment and health care operations, or to comply with legal, regulatory or accreditation requirements. Medica’s full Privacy Notice is available upon request by calling (855) 347-5010 (TTY: 711 ) or by going to Medica.com/Privacy .
To qualify for a Medica plan, you must be a resident of Wisconsin, and not eligible for or enrolled in Medicare. You also must live within your selected network’s service area to enroll in and remain in the plan. Understanding Benefits and Coverage Details This brochure is a brief overview of the plans. For complete benefit details, limitations, and exclusions please see a Medica Individual and Family insurance policy. This can be found by visiting Medica.com/ Plans4WI or request a paper copy by calling (855) 347-5010 (TTY: 711 ). Prior Approvals and Excluded Services Some services and procedures require prior approval from Medica before they are covered. Services not covered include, but are not limited to, custodial care, adult eyewear, most dental services, cosmetic services, refractive eye surgery, those received while on military duty and services that are investigational or not medically necessary. For a complete list, see a Medica Individual and Family insurance policy available on Medica.com/Plans4WI or call (855) 347-5010 (TTY: 711 ). Pediatric Dental is Not Covered These policies do not include pediatric dental services. Pediatric dental is an essential health benefit that can be purchased as a standalone product through the Health Insurance Marketplace. For more information visit healthcare.gov . Member Complex Case Management We have services and programs designed to help members with certain health conditions manage their overall care and treatment. Find more information about the programs and services available by visiting Medica.com/Plans4WI. Health Savings Account The Bronze HSA plan can be paired with a health savings account (HSA) — which is a special savings account for IRS-approved medical expenses. Generally, Cost Share Reduction (CSR) plans cannot be paired with an HSA. Learn more about the benefits of an HSA or how to open an account by visiting Medica.com/HSA .
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