UIChoice Plan Provisions
Common Medical Plan Terms and Definitions
Amount of money you pay out-of-pocket for care before plan begins to pay for benefits.
Percentage you pay for covered services after you've reached your deductible.
Flat dollar amount you'll pay for covered services at the time of service.
Most you pay for covered services in plan year after
paying deductibles, copays & coinsurance.
|Level 1 Providers||Level 2 Providers||Level 3 Providers|
|Annual Deductible1||None. Visit Annual Inpatient Deductible below|
|Annual Inpatient Care Deductible||$400 deductible, followed by 10% coinsurance||$600 deductible, followed by 10% coinsurance||$800 deductible, followed by 40% coinsurance|
|Annual Out-of-Pocket Maximum (OPM)||Single: $1,700
|Annual OPM for Non-Participating Providers2||N/A||N/A||Single: $2,000
|Coinsurance||10%||20%||Varies based on location & service|
|Copay||$10 copay||$25 copay||No copay. Subject to coinsurance depending on service.|
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.
2) The OPM for services from non-participating Level 3 providers is separate from the OPM for services from Level 1, Level 2, and participating Level 3 providers. 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 individual OPM, but the combination of the out-of-pocket expenses for all the plan members meets the appropriate OPM for the plan.
|Level 1 Providers||Level 2 Providers||Level 3 Providers|
|Preventive Care3||Plan pays 100%||Plan pays 100%||Plan pays 100%|
|Preventive Care Non-Participating Providers||N/A||N/A||Outpatient: 40% coinsurance
In office: 50% coinsurance
|Office Visits||$10 copay||$25 copay||Member pays 50% coinsurance|
|Mental Health Visits||Plan pays 100%||Plan pays 100%||Member pays 50% coinsurance|
|Routine Eye and Hearing Exams||$10 copay
1 per calendar year
1 per calendar year
|Member pays 50% coinsurance
1 per calendar year
|Doc on Demand4||$0 copay||$0 copay||$0 copay|
|UI QuickCare||$5 copay||N/A||N/A|
|Urgent Care||$10 copay||$25 copay||Member pays 50% coinsurance|
|Emergency Room Visits5||$100 copay followed by 10% coinsurance||$100 copay followed by 10% coinsurance||$100 copay followed by 10% coinsurance|
|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 is able to provide ASL (American Sign Language) and spoken language interpretation for medical visits.
5) When care is necessitated by an emergency, 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 which 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 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 annual max and are calculated using billed charge. Orthotics, include shoes, are covered.
Other Covered Services, Excluded Services & FAQ's
- Applied Behavior Analysis therapy-covered through age 18
- Bariatric surgery
- Chiropractic Care
- Hearing aids (20% coinsurance up to $2,000 every 5 years)
- 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 - Adult and Children (unlimited exams)
- Gender Transition Surgery - All of the health plans offered through the University of Iowa provide benefits for medically necessary covered services associated with gender transition when ordered by a health professional. Please contact Wellmark Blue Cross and Blue Shield at 800-643-9724 for more information and to discuss the gender transition medical policy.
- Cosmetic surgery
- Custodial care - in home or facility
- Dental Care - Adult
- Dental check-up
- Extended home skilled nursing
- Long-term care
- Routine foot care
- Weight loss programs
All of the health plans offered through the University of Iowa, which Wellmark Blue Cross and Blue Shield of Iowa, provides coverage of medically necessary covered services associated with gender transition-related treatment.
Wellmark Blue Cross and Blue Shield of Iowa follow the national standards set forth by the World Professional Association for Transgender Health (WPATH) when deeming if a covered service is medically necessary.
Covered services, when ordered by a health professional and deemed medically necessary associated with gender transition-related treatment, may include the following:
- Hormone therapy;
- Mental health services; and
- Chest/breast and genital surgeries when ordered by a health professional.
Please contact Wellmark Blue Cross and Blue Shield of Iowa at 800-643-9724 for more information and discuss the gender transition medical policy within the Interqual Prior Approval program to assure you have met all qualifications.
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.
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 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.
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.