Essence (HMO-POS)
H5211 - 003 - 0
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Essence (HMO-POS) is a Medicare Advantage (Part C) Plan by Security Health Plan of Wisconsin, Inc..
This page features plan details for 2024 Essence (HMO-POS) H5211 – 003 – 0 available in Central, North, Northeast, West & South Central WI.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Essence (HMO-POS) is offered in the following locations.
Plan Overview
Essence (HMO-POS) offers the following coverage and cost-sharing.
| Insurer: | Security Health Plan of Wisconsin, Inc. |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,400 In and Out-of-network $3,400 In-network $3,400 Out-of-network |
| Drugs Covered: | No |
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Premium Breakdown
Essence (HMO-POS) has a monthly premium of $20.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $20.00 | $0.00 | $194.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Essence (HMO-POS) also provides the following benefits.
| $0 |
| In-network | Yes |
| $3,400 In and Out-of-network $3,400 In-network $3,400 Out-of-network |
| Yes |
| In-network | Yes, contact plan for further details |
| In-network | $0-200 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | $0-200 copay per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| out-of-network Primary | $0 copay (Not applicable.) (Not applicable.) |
| In-network Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $125 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0-50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | $5 copay (Authorization is required.) (Referral is not required.) |
| In-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $200 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | $200 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient x-rays | $5 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | $5 copay (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $50 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $50 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $50 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | $50 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Hearing aids | $500 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| In-network Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0-50 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | $0-50 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| In-network Other | $0-50 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Other | $0-50 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | $20 copay (Authorization is required.) (Referral is not required.) |
| In-network | $200 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay (Authorization is required.) (Not applicable.) |
| Covered (Authorization is required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 6 $20 per day for days 7 through 45 $0 per day for days 46 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 6 $20 per day for days 7 through 45 $0 per day for days 46 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $43.00 |
| Deductible | $100.00 |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $43.00 |
| Preventive dental: | Deductible: | $100.00 |
| Comprehensive dental: | Monthly Premium: | $43.00 |
| Comprehensive dental: | Deductible: | $100.00 |
Ready to sign up for Essence (HMO-POS) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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