Copayments, Co-insurance, Deductibles - UIChoice

Health care under the UIChoice plan may be obtained from any provider you wish. The provider you choose determines the plan benefit level and how much you pay.

Office Visits

2018 - effective January 1, 2018 - December 31, 2018
  Level 1 Level 2 Level 3
Office Visits $10 copayment $25 copayment 50% co-insurance
UI QuickCare $5 copayment N/A N/A
UIeCare Free for covered employees and dependents on UIChoice
2017 - effective January 1, 2017 - December 31, 2017
  Level 1 Level 2 Level 3
Office Visits $5 copayment $20 copayment 40% co-insurance
UIeCare Free for covered employees and dependents on UIChoice

Office Visits Include visits to primary care providers, specialists, chiropractors, and urgent care clinics

Routine Annual Physical Examination, Preventive care Services, Well Child

2018 - effective January 1, 2018 - December 31, 2018
  Level 1 Level 2 Level 3
Preventative Care $0 copayment $0 copayment 40% co-insurance if outpatient
50% co-insurance if in office
*co-insurance waived for immunizations and well-child care
Imaging & Lab Services 10% co-insurance 10% co-insurance 40% co-insurance
Routine Eye Exam $10 copayment $25 copayment 50% co-insurance
Routine Hearing Exam $10 copayment $25 copayment 50% co-insurance

For 2018, there is no physician charge or copayment for a routine annual physical examination from a level 1 or 2 or participating level 3 provider, and 50% co-insurance applies for a Level 3 non-participating provider. There is a charge for non-preventive care labs, tests, and imaging on all levels. Preventive care services are not subject to co-insurance if received from a Level 1 or Level 2 or participating Level 3 provider.  Level 3 non-participating providers are subject to 50% co-insurance.

There is no copayment or co-insurance for well-child care (children up to seven years of age).

2017 - Effective January 1, 2017 - December 31, 2017
  Level 1 Level 2 Level 3
Preventative Care $0 copayment $0 copayment 40% co-insurance
*co-insurance waived for immunizations and well-child care
Imaging & Lab Services 10% co-insurance 10% co-insurance 40% co-insurance
Routine Eye Exam $5 copayment $20 copayment 40% co-insurance
Routine Hearing Exam $5 copayment $20 copayment 40% co-insurance

There is no physician charge or copayment for a routine annual physical examination from a level 1 or 2 or participating level 3 provider, and 40% co-insurance applies for a Level 3 non-participating provider. There is a charge for non-preventive care labs, tests, and imaging on all levels. Preventive care services are not subject to co-insurance if received from a Level 1 or Level 2 or participating Level 3 provider.  Level 3 non-participating providers are subject to 40% co-insurance.

There is no copayment or co-insurance for well-child care (children up to seven years of age).

 

Emergency Care

2018- effective January 1, 2018 - December 31, 2018
  Level 1 Level 2 Level 3
Emergency Room Care $100 copayment followed by
10% co-insurance
$100 copayment followed by
10% co-insurance
$100 copayment followed by
10% co-insurance if coded as an emergency.
If not coded as an emergency, $100 copayment followed by 40% co-insurance 

When care is necessitated by an emergency, the individual's share of the emergency room costs will include a $100 copayment and 10% of the charges with Level 1 and 10% of the charges with Level 2 providers. Level 3 providers will be the same unless the visit is not coded as an emergency, then there will be a $100 copayment and 40% co-insurance. The $100 copayment is waived regardless of the provider level if you are admitted to the hospital.

2017 - effective January 1, 2017 - December 31, 2017
  Level 1 Level 2 Level 3
Emergency Room Care $50 copayment followed by
10% co-insurance
$50 copayment followed by
10% co-insurance
$50 copayment followed by
10% co-insurance if coded as an emergency.
If not coded as an emergency,
$50 copayment followed by 40% co-insurance

When care is necessitated by an emergency, the individual's share of the emergency room costs will include a $50 copayment and 10% of the charges with Level 1 and 10% of the charges with Level 2 providers. Level 3 providers will be the same unless the visit is not coded as an emergency, then there will be a $50 copayment and 40% co-insurance. The $50 copayment is waived regardless of the provider level if you are admitted to the hospital.

 

Hospital Services

2017 and 2018 - no changes. Effective January 1, 2017 - December 31, 2018
  Level 1 Level 2 Level 3
Inpatient Care (semi-private room) $400 deductible followed by
10% co-insurance
$600 deductible followed by
10% co-insurance
$800 deductible followed by
40% co-insurance
Facility Fees 10% co-insurance 10% co-insurance 40% co-insurance
Inpatient Surgery 10% co-insurance 10% co-insurance 40% co-insurance
Outpatient Surgery 10% co-insurance 20% co-insurance 40% co-insurance
Physician Care 10% co-insurance 20% co-insurance 40% co-insurance
Labs and Imaging 10% co-insurance 20% co-insurance 40% co-insurance

 After the deductible is paid, the individual will pay the corresponding co-insurance per level of provider, subject to the out-of-pocket maximum limits.

The co-insurance for outpatient hospital services including outpatient surgery, physician care, supplies, labs & imaging is 10% for level 1 providers, 20% for level 2 providers, and 40% for Level 3 providers - again, subject to the out-of-pocket maximum limits. A copayment may also apply.

Durable Medical Equipment

Insureds will pay 20% for durable medical equipment.

This website provides a general summary of the basic benefit provisions and is not a substitute for the coverage manual. If there are any inconsistencies between this summary and the coverage manual, the coverage manual will prevail. Please refer to the coverage manual for exact benefits, exclusions, and limitations or contact Wellmark’s customer service at 1-800-622-0043.