Spirit (HMO-POS) is a Medicare Advantage (Part C) Plan by Security Health Plan of Wisconsin, Inc..
This page features plan details for 2024 Spirit (HMO-POS) H5211 – 001 – 0 available in Central, North, Northeast, West & South Central WI.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Spirit (HMO-POS) is offered in the following locations.
Spirit (HMO-POS) offers the following coverage and cost-sharing.
Insurer: | Security Health Plan of Wisconsin, Inc. |
Health Plan Deductible: | $0.00 |
MOOP: | $1,500 In and Out-of-network $1,500 In-network $1,500 Out-of-network |
Drugs Covered: | No |
Ready to sign up for Spirit (HMO-POS) ?
Part B | Part C | Part B Give Back | Total |
---|---|---|---|
$174.70 | $139.00 | $0.00 | $313.70 |
Spirit (HMO-POS) also provides the following benefits.
$0 |
In-network | Yes |
$1,500 In and Out-of-network $1,500 In-network $1,500 Out-of-network |
Yes |
In-network | Yes, contact plan for further details |
In-network | $0-100 copay per visit (Authorization is required.) (Referral is not required.) |
out-of-network | $0-100 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 | $25 copay per visit (Authorization is not required.) (Referral is not required.) |
out-of-network Specialist | $25 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 | $0-25 copay per visit (always covered) (Not applicable.) (Not applicable.) |
In-network Diagnostic tests and procedures | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic tests and procedures | $0 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) | $150 copay (Authorization is required.) (Referral is not required.) |
out-of-network Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
In-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
In-network Fitting/evaluation | $25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
out-of-network Fitting/evaluation | $25 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 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
out-of-network Routine eye exam | $0-25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
In-network Other | $25 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
out-of-network Other | $0-25 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 | $150 copay (Not applicable.) (Not applicable.) |
Not covered (Not applicable.) (Not applicable.) |
In-network Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Foot exams and treatment | $25 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 | $250 per stay (Authorization is required.) (Referral is not required.) |
out-of-network | $250 per stay (Authorization is required.) (Referral is not required.) |
In-network Inpatient hospital – psychiatric | $250 per stay (Authorization is required.) (Referral is not required.) |
out-of-network Inpatient hospital – psychiatric | $250 per stay (Authorization is required.) (Referral is not required.) |
In-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
In-network Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
In-network Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
out-of-network Outpatient individual therapy visit | $25 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 20 $0 per day for days 21 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 20 $0 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
Monthly Premium | $43.00 |
Deductible | $100.00 |
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 Spirit (HMO-POS) ?
SMID: MULTIPLAN_HCIHNDOGMED01_M
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