Aspirus Health Plan
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HMO Silver 5000 - HMO

Plan summary
Get our guide to the Essential Health Benefits covered by this plan and all other Marketplace plans.
Monthly premium
Your premium is the amount you pay for health insurance each month.
Deductible
$5,000 per person
$5,000 per person
Your deductible is the amount you pay for healthcare services before your insurance starts helping you cover the cost.
Depending on the plan, some basic services (like doctor visits and prescriptions) may be covered before your deductible is met.
Out-of-pocket max
$8,000 per person
$16,000 per family
This is the most you will have to pay for healthcare services during your coverage period (typically 12 months).
After you spend this amount on deductibles, copayments, and coinsurance, your health insurance plan will pay the rest.
Note: monthly premiums don’t count towards your out-of-pocket max.
Network type
HMO
The type of network you choose (HMO, PPO, POS, or EPO) will determine which providers (doctors, pharmacies, hospitals, and specialist) you can see.
• HMO plans usually limit coverage to providers who are within the plan’s network, and require a doctor’s referral to see specialists.
• PPO plans usually cover some of the cost of out-of-network providers (but not as much as for in-network providers), and don’t require a doctor’s referral to see specialists.
• EPO is a managed care plan where services are covered only if you go to doctors, specialists, or hospitals in the plan’s network (except in an emergency).
Metal tier
Silver
Metal levels (which include bronze, silver, gold, and platinum) determine how you will split the cost of your healthcare services with your insurance carrier.
• Bronze plans have the lowest monthly premiums and the highest costs when you need care
• Silver plans have moderate monthly premiums and moderate costs when you need care.
• Gold plans have high monthly premiums and low costs when you need care.
• Platinum plans have the highest monthly premiums and the lowest costs when you need care.
Doctor visits
This can include any visits to your doctors (outside of regular checkups) within your plan's network.
Primary care visit
$40 copay
MH/SUD/telehealth office visits are considered the same benefits as a primary care physician. Catastrophic plan includes 3 free visits, see summary of benefits for additional details.
This is the amount you’re responsible for when receiving primary care services.
For example, this could be an appointment with your primary care provider for a routine checkup or screening.
Specialist visit
$80 copay
This is the amount you’re responsible for when visiting a specialist (a medical professional who specializes in different types of diseases or conditions).
For example, a dermatologist, cardiologist, or pathologist.
Preventive care visit
No charge
Excludes: No coverage for services provided by a non-participating provider.
There are dozens of preventive care services available for free with every plan, including check-ups, counseling, screenings, and immunizations
To learn more, scroll down to the Free Preventive Care section below.
Emergency / Surgery
These are the costs you’re responsible for in the case of an emergency or surgery.
Urgent care
$60 copay
Services provided by a non-participating provider will be paid at the participating provider level if for emergency medical care.
An urgent care center can be a convenient option if you have a non-life-threatening injury and your doctor is not available.
Urgent care is usually less expensive than going to the Emergency Room, and will usually have shorter wait times for non-life-threatening injuries.
Emergency room
40% coinsurance after deductible
Services provided by a non-participating provider will be paid at the participating provider level.
This is the amount you’re responsible for when receiving emergency room services.
Ambulance
40% coinsurance after deductible
Services provided by a non-participating provider will be paid at the participating provider level.
This is the amount you’re responsible for when receiving ambulatory services.
Hospital stay (facility)
40% coinsurance after deductible
This is the amount you’re responsible for when using the facilities and equipment at a hospital.
Hospital stay (physician)
40% coinsurance after deductible
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, medical doctor, or other specialist.
Outpatient procedure (facility)
40% coinsurance after deductible
This is the amount you’re responsible for when using the equipment and facilities at a hospital.
Specifically, during a procedure that does not require overnight hospitalization.
Outpatient procedure (physician)
40% coinsurance after deductible
This is the amount you’re responsible for when receiving services provided by a physician, surgeon, or other specialist.
Specifically, during a procedure that does not require overnight hospitalization.
Physical rehabilitation
$40 copay
Coverage is limited to 20 visits per year for physical thearpy and 20 visits per year for occupational thearpy. Excludes: No coverage for therapy for attention deficit disorder, hyperactivity disorder, sensory defensiveness, mental retardation, and related conditions; biofeedback; long-term and maintenance therapy.
This includes physical and occupational therapy, speech pathology, and psychiatric rehabilitation services.
Pregnancy
Every ACA health insurance plan covers healthcare services provided before and after your child is born. Here is a breakdown of the costs associated with your plan.
Well baby care
$40 copay
Excludes: No coverage for services provided by a non-participating provider.
This is the amount you’re responsible for when receiving well baby care.
These services may include developmental screenings, counseling, behavioral assessments, plus more.
Labor, delivery, hospital stay
40% coinsurance after deductible
This is the amount you will pay for your labor, delivery, and hospital stay.
Prescriptions
Prescription coverage and cost is usually based on a tiered structure. These tiers are determined by generic, brand, or speciality drugs.
Generic
$20 copay
See brochure for a listing of free preventive drugs.
This is the amount you will pay for a generic drug prescription.
Brand
$40 copay
This is the amount you will pay for a brand name drug prescription.
Non-preferred Brand
$80 copay after deductible
This is the amount you will pay for a non-preferred brand name drug prescription.
Specialty
$350 copay after deductible
This is the amount you will pay for a speciality drug prescription.
Diagnostics / Labs / Imaging
This is the amount you're responsible for when receiving blood work, tests, or x-rays your doctor may need for diagnosing.
X-rays
40% coinsurance after deductible
This is the amount you’re responsible for when having an x-ray.
Imaging (CT/PET/MRI)
40% coinsurance after deductible
This is the amount you’re responsible for when having an MRI, CET, PET scan.
Blood work
40% coinsurance after deductible
This is the amount you’re responsible for when receiving blood work.
Mental health
Under the Affordable Care Act, all Marketplace plans are required to cover behavioral health treatment, mental and behavioral health inpatient services, as well as substance use treatment.
Outpatient services
$40 copay
MH/SUD/telehealth office visits are considered the same benefits as a primary care physician. All other outpatient services apply to deductible and coinsurance.
This is the amount you’re responsible for when you have a procedure that does not require overnight hospitalization.
Psychiatric hospital stay
40% coinsurance after deductible
This is the amount you’re responsible for when you’re admitted or receiving treatment at a psychiatric hospital.
The Affordable Care Act requires that all health insurance plans cover preventive care for free. Preventive care services focus on managing and maintaining your health before something becomes serious. This includes routine check-ups, counseling, screenings, and immunizations. Grab our free guide to preventive care to refer back to later.
Abdominal aortic aneurysm one-time screening
For men of specified ages who have ever smoked
Free
Alcohol misuse screening and counseling
To prevent cardiovascular disease for men and women of certain ages
Free
Free
Free
Cholesterol screening
For adults of certain ages or at higher risk
Free
Colorectal cancer screening
For adults over 50
Free
Free
Diabetes (Type 2) screening
For adults with high blood pressure
Free
Diet counseling
For adults at higher risk for chronic disease
Free
Hepatitis B screening
For people at high risk
Free
Hepatitis C screening
For adults at increased risk, and one time for everyone born 1945 – 1965
Free
HIV screening
For everyone ages 15 to 65, and other ages at increased risk
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Free
Lung cancer screening
For adults 55 - 80 at high risk for lung cancer
Free
Free
Free
Syphilis screening
For adults at higher risk and all pregnant women
Free
Tobacco Use screening
For all adults and cessation interventions for tobacco users
Free
Official documents
If you'd like to see the official documents from the health insurance company, we've provided links to those here.
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