Plan Provisions
The plan provisions chart below should be used as a general guide only. Please refer to the UIChoice Coverage Manual (pdf) for further information. If the information provided in this summary chart differs from the coverage manual, the UIChoice Wellmark Coverage Manual document will govern.
Common Medical Plan Terms and Definitions
Deductible
Amount of money you pay out-of-pocket for care before plan begins to pay for benefits.
Coinsurance
Percentage you pay for covered services after you've reached your deductible.
Copay
Flat dollar amount you'll pay for covered services at the time of service.
OPM
Most you pay for covered services in plan year after
paying deductibles, copays & coinsurance.
| Level 1 | Level 2 | Level 3 | |
|---|---|---|---|
| Annual Deductible1 | N/A. Deductible for inpatient hospital care only. Visit annual inpatient care deductible below. | ||
| Inpatient Care Deductible semi-private room | $500 deductible, followed by 10% coinsurance per admission | $750 deductible, followed by 10% coinsurance per admission | $1,000 deductible, followed by 40% coinsurance per admission |
| Coinsurance | 10% | 20% | Varies based on location & service |
| Annual Out-of-Pocket MEDICAL Maximum (OPM) | Levels 1 and 2 Blue Card participating providers combined: Single: $2,000 | Level 3 Blue Card participating and non-participating providers (eff. 1/1/25): Single: $2,500 | |
| Annual PRESCRIPTION Out-of-Pocket Maximum (OPM) | Single: $1,850 Family: $3,700 | ||
1) UIChoice does not have a typical deductible like the UISelect plan. This plan has a deductible for inpatient care only. Once you pay the deductible, you are responsible for the applicable coinsurance, depending on what level the provider is participating in.
2) The OPM for services from participating and non-participating Level 3 providers is separate from those from Levels 1 and 2. If a plan member meets the individual OPM, the additional plan member(s) continue to pay coinsurance and deductibles until the larger OPM for their plan is met. The OPM can also be met when no individual plan member meets their OPM, but the combination of the out-of-pocket expenses for all the plan members meets the appropriate OPM for the plan.
| Level 1 | Level 2 | Level 3 | |
|---|---|---|---|
| Preventive Care3 | $0 copay | $0 copay | Participating Providers: $0 copay Non-participating Providers: 0% coinsurance, |
| Doc on Demand4 | $0 copay | $0 copay | $0 copay |
| UI QuickCare | $10 copay | N/A | N/A |
| Urgent Care | $15 copay | $30 copay | 50% coinsurance |
| Office Visits | $15 copay | $30 copay | 50% coinsurance |
| Emergency Room Visits5 | $125 copay followed by 10% coinsurance | ||
| Mental Health Visits | $0 copay | $0 copay | 50% coinsurance |
| Routine Eye and Hearing Exams | $15 copay 1 per calendar year | $30 copay 1 per calendar year | 50% coinsurance 1 per calendar year |
| Facility Fees | Member pays 10% coinsurance | Member pays 10% coinsurance | Member pays 40% coinsurance |
| Inpatient Surgery | Member pays 10% coinsurance | Member pays 10% coinsurance | Member pays 40% coinsurance |
| Outpatient Surgery6 | Member pays 10% coinsurance | Member pays 20% coinsurance | Member pays 40% coinsurance |
| Physician Care + Labs & Imaging | Member pays 10% coinsurance | Member pays 20% coinsurance | Member pays 40% coinsurance |
| Home Health Care | Member pays 10% coinsurance | Member pays 10% coinsurance | Member pays 40% coinsurance |
| Skilled Nursing Care | Member pays 10% coinsurance | Member pays 10% coinsurance | Member pays 40% coinsurance |
| Hospice Services7 | Member pays 10% coinsurance | Member pays 10% coinsurance | Member pays 40% coinsurance |
| Durable Medical Equipment8 | Member pays 20% coinsurance | Member pays 20% coinsurance | Member pays 20% coinsurance |
3) There is no physician charge or copay for a routine annual physical exam from a level 1, level 2, or participating level 3 provider and 50% coinsurance applies for a level 3 non-participating provider. There is a charge for non-preventive care labs, tests, and imaging on all levels. Coinsurance is waived for immunizations and well-child care (children up to 7 years of age).
4) Doctor on Demand is free care anywhere 24/7 for covered employees and their dependents. With Doc on Demand, you can have video visits with board-certified physicians and get treatment and prescriptions (member cost-share applies) for a cold, flu, allergies, and more. Doctor on Demand can provide ASL (American Sign Language) and spoken language interpretation for medical visits.
5) When an emergency necessitates care, the individual's share of the emergency room costs will include a $100 copay and 10% coinsurance of the charges with Level 1 and Level 2 providers. Level 3 providers will be the same unless the visit is not coded as an emergency; in this case, there will be a $100 copay and 40% coinsurance. The $100 copay is waived regardless of the provider level if you are admitted to the hospital. The coinsurance follows the copay because the copay will be first subtracted from the allowed amount for the hospital facility charge, and the 10% coinsurance will be applied to the remaining allowed amount. For emergency medical conditions treated out-of-network, you may be balanced billed.
6) The coinsurance for outpatient hospital services, including outpatient surgery, physician care, supplies, labs, and imaging, is 10% for Level 1 providers, 20% for Level 2 providers, and 40% for Level 3 providers, subject to the out-of-pocket maximum limits. A copay may also apply.
7) Hospice respite care is limited to 15 inpatient and 15 outpatient days per lifetime.
8) Wigs are covered following chemotherapy up to $1,000 annually and are calculated using billed charges. Orthotics, including shoes, are covered.
Other Covered Services, Excluded Services & FAQ's
Other Services Covered
- Applied Behavior Analysis therapy-covered through age 18
- Bariatric surgery
- Chiropractic Care
- All benefit levels include a 20% coinsurance for hearing aids and hearing aid evaluation. The plan will pay 80% up to a $1,500 limit every 36 months.
- Infertility treatment ($25,000 Life Time Maximum, Level 2: 30% coinsurance)
- Most coverage provided outside the U.S.
- Private-duty nursing - short-term intermittent home skilled nursing
- Routine eye care - Adults and Children (unlimited exams)
Excluded Services
- Acupuncture
- Cosmetic surgery
- Custodial care - in home or facility
- Dental Care - Adult
- Dental check-up
- Extended home skilled nursing
- Glasses
- Long-term care
- Routine foot care
- Weight loss programs
How is physical therapy covered?
How is physical therapy covered?
Office-based physical therapy will be covered with an office copay amount being owed. Facility-based physical therapy when received in a hospital will be covered as ‘inpatient or outpatient’ with coinsurance being owed.
*NOTE: For UISelect, facility-based physical therapy covered as ‘inpatient or outpatient’ will be subject to the deductible.
How long do I need to wait between my preventive physical exams?
UIChoice: Preventive physical exams, including female gyn exams and pap smears, and preventive mammograms have no benefit period (calendar year) limit.
UISelect: One preventive physical exam (includes separate female gyn exam and pap smear) and one preventive mammogram per benefit period (calendar year) is covered.
How does coordination of benefits works for retirees with Medicare?
How does the coordination of benefits work for retirees when Medicare Parts A & B are primary and UIChoice or UISelect are secondary?
The process in how the claims are handled for retirees will be the same for either UIChoice or UISelect regarding coordination of benefit. Depending upon the medical service received and the coverage of the medical service, and if the medical service is subject to the deductible, there could be an amount owed under either plan. However, it should not be greater than the deductible for covered medical services.
Basic Insurance Terms
Deductible: the amount you owe for covered health care services before your health plan begins to pay.
- UISelect: the deductible applies when receiving covered health care services subject to a coinsurance; applied only 1 time during the plan year.
- UIChoice: the deductible applies to inpatient facility services only; applied for each admission during the plan year.
Copayment (Copay): a fixed dollar amount you pay for a covered health care service, typically when you receive the service.
Coinsurance: your share of a covered health care service, calculated as a percentage (ex: 20%).
Out-of-pocket maximum (OPM): the maximum amount you pay, out of your pocket, for covered health care services during a plan year. The deductible, copays, and coinsurance amounts apply toward the OPM.
Have a Question?
The information presented on our website describes only the highlights of the plans and does not constitute official plan documents. Additional terms and conditions may apply. If there are any discrepancies between the information contained herein and the official plan documents, the plan documents will govern. For more detailed information you may contact Wellmark Blue Cross/Blue Shield at toll-free number 800-524-9242 (TTY: 888-781-4262), Monday through Friday from 7:30 a.m. to 5:00 p.m. (Central Time). For more efficient service, please have your member ID number handy - it can be found on the front of your card.