Essence (HMO-POS)
Health Insurance Company: Security Health Plan of Wisconsin, Inc.
Medicare Advantage Plan Details
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $50 copay per visit
Out-of-network: $0 copay
Emergency Room
$125 copay per visit (always covered)
Ambulance Coverage
In-network: $200 copay
Out-of-network: No Data
Lab, X-Ray, Radiology Coverage
Outpatient diag procs/tests/lab services:
Medicare-covered diagnostic procedures/tests: In-network: $5 copay
Out-of-network: $5 copay
Medicare-covered lab services: In-network: $0 copay
Out-of-network: $0 copay
Outpatient diag/therapeutic rad services:
Medicare-covered diagnostic radiological services (e.g., CT, MRI, etc): In-network: $200 copay
Out-of-network: $200 copay
Medicare-covered x-ray services: In-network: $5 copay
Out-of-network: $5 copay
Outpatient Surgery Coverage
Outpatient hospital:
Medicare-covered outpatient hospital services: In-network: $0-200 copay per visit
Out-of-network: $0-200 copay per visit
Hospitalization Coverage
Inpatient hospital-acute:
In-network: $300 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: $300 per day for days 1 through 5
$0 per day for days 6 through 90
Inpatient hospital psychiatric:
In-network: $300 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: $300 per day for days 1 through 5
$0 per day for days 6 through 90
Rehabilitation Coverage
Occupational therapy services:
In-network: $20 copay
Out-of-network: $20 copay
Physical therapy and speech and language therapy services:
In-network: $20 copay
Out-of-network: $20 copay
Urgent Care Coverage
$0-50 copay per visit (always covered)
Skilled Nursing Facility (SNF)
In-network: $0 per day for days 1 through 6
$20 per day for days 7 through 45
$0 per day for days 46 through 100
Out-of-network: $0 per day for days 1 through 6
$20 per day for days 7 through 45
$0 per day for days 46 through 100
Mental Health Coverage
Medicare-covered individual sessions: In-network: $40 copay
Out-of-network: $40 copay
Medicare-covered group sessions: In-network: $40 copay
Out-of-network: $40 copay
Dental, Vision, Hearing Benefits
Dental Services
Oral exams: In-network: $0 copay
Out-of-network: No Data
Prophylaxis (cleaning): In-network: $0 copay
Out-of-network: No Data
Dental x-rays: In-network: $0 copay
Out-of-network: No Data
Vision Benefits
Eye exams:
Routine eye exams: In-network: $0-50 copay
Out-of-network: $0-50 copay
Eyewear:
Contact Lenses: Not covered
Eyeglasses: In-network: $0 copay
Out-of-network: No Data
Hearing Benefits
Hearing exams:
Routine hearing exams: In-network: $50 copay
Out-of-network: $50 copay
Hearing aids:
Hearing aids (all types): In-network: $500 copay
Out-of-network: No Data
Plan Links
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