Copayments, Coinsurance, Deductibles and OPM

UIChoice
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.

PLAN PROVISIONS:

Deductible = The amount of money you pay out of pocket for care before your plan begins to pay for benefits. Under the UIChoice health plan, the deductible applies to inpatient facility services only.
Coinsurance = The percentage you pay for covered services after you've reached your deductible.
Copayment = The flat dollar amount you'll pay for covered services at the time of service.
Out-of-Pocket Maximum (OPM) = The most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments and coinsurance, the plan pays 100 percent of covered services.

For a printable overview, visit our PDF iconKey Insurance Terms and Plan Provisions Summary (pdf)

  LEVEL 1 LEVEL 2 LEVEL 3
Deductible NONE
Note that there is a deductible for inpatient hospital care only. Visit Hospital Services for details.
Coinsurance 10% 20% Coinsurance varies based on location and type of service
Copayments $10 $25 No Copayment
Out-of-Pocket Maximum (OPM)

Levels 1, 2 and 3 Blue Card participating providers combined:
$1,700 single / $3,400 family

Prescription Drugs:
$1,100 single / $2,200 family

Non-Participating Providers: N/A Non-participating providers: $2,000 single / $4,000 family

Out-of-Pocket Maximum (OPM)

The UIChoice Plan provides an annual maximum limit for the out-of-pocket (OPM) expenses for both individuals and families. When the amount paid in co-insurance and deductibles equals the applicable OPM, the plan pays 100% of the covered charges for most additional medically-necessary expenses incurred during the remainder of the calendar year.

NOTE: 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.  The OPM for covered services received from non-participating Level 3 providers is $2,000 per person and $4,000 per family.

If a plan member meets the individual OPM, the additional plan member/s continue to pay co-insurance and deductibles until the larger OPM for their contract 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 contract OPM

Office Visits

2019 - effective January 1, 2019 - December 31, 2019
  Level 1 Level 2 Level 3
Office Visits $10 copayment $25 copayment 50% coinsurance
UI Urgent Care Clinic $10 copayment N/A N/A
UI QuickCare $5 copayment N/A N/A
Doctor on Demand 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

2019 - effective January 1, 2019 - December 31, 2019
  Level 1 Level 2 Level 3
Preventative Care $0 copayment $0 copayment 40% coinsurance if outpatient
50% coinsurance if in office
*coinsurance waived for immunizations and well-child care
Imaging & Lab Services 10% coinsurance 10% coinsurance 40% coinsurance
Routine Eye Exam $10 copayment $25 copayment 50% coinsurance
Routine Hearing Exam $10 copayment $25 copayment 50% coinsurance

For 2019, 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% coinsurance 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 coinsurance if received from a Level 1 or Level 2 or participating Level 3 provider.  Level 3 non-participating providers are subject to 50% coinsurance.

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

Emergency Care

2019- effective January 1, 2019 - December 31, 2019
  Level 1 Level 2 Level 3
Emergency Room Care $100 copayment followed by
10% coinsurance
$100 copayment followed by
10% coinsurance
$100 copayment followed by
10% coinsurance if coded as an emergency.
If not coded as an emergency, $100 copayment followed by 40% coinsurance 

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% coinsurance. The $100 copayment is waived regardless of the provider level if you are admitted to the hospital.

Hospital Services

Effective January 1, 2019 - December 31, 2019
  Level 1 Level 2 Level 3
Inpatient Care (semi-private room) $400 deductible followed by
10% coinsurance
$600 deductible followed by
10% coinsurance
$800 deductible followed by
40% coinsurance
Facility Fees 10% coinsurance 10% coinsurance 40% coinsurance
Inpatient Surgery 10% coinsurance 10% coinsurance 40% coinsurance
Outpatient Surgery 10% coinsurance 20% coinsurance 40% coinsurance
Physician Care 10% coinsurance 20% coinsurance 40% coinsurance
Labs and Imaging 10% coinsurance 20% coinsurance 40% coinsurance

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

The coinsurance 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% coinsurance for durable medical equipment.


ABOUT OUR SITE:
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.