Important Benefit Information

All MDwise Marketplace products include ten essential health benefits. They are required under the Affordable Care Act. They include:
  1. Ambulatory patient services (care you get without being admitted to a hospital, like at a clinic or doctor’s office).
  2. Emergency services.
  3. Hospitalization.
  4. Maternity and newborn care (care given to women during pregnancy and care after baby is born).
  5. Mental health and substance use disorder services, including behavioral health treatment (care for mental health and substance abuse).
  6. Prescription drugs.
  7. Rehabilitative and habilitative services and devices (services and devices to help people with injuries, disabilities or chronic conditions gain or recover mental and physical skills).
  8. Laboratory services.
  9. Preventive and wellness services and chronic disease management (includes routine physicals and immunizations/shots).
  10. Pediatric services (services covered for children, includes vision care).

Your member policy has the full list of covered services and limitations of coverage. You can access your policy by creating or logging in to your ​myMDwise account.

To see the out-of-pocket cost associated with a specific service, please refer to your Summary of Benefits and Coverage (SBC). Your SBC can be found in myMDwise.
 

Deductible: The amount of money you have to pay before the health plan begins to pay. For example, if your deductible is $500, your health plan won’t pay for covered health services until you meet your $500 deductible.

Out-of-pocket costs: Medical expenses that aren’t reimbursed by insurance and you have to pay. This includes costs for services that aren’t covered by your plan.


You have a deductible you are responsible for paying. The amount of the deductible depends on the metal level plan you chose (bronze, silver or gold). You will have to pay the allowed amount for services you receive until your deductible is met. The following are exceptions where you don’t have to reach your deductible before you pay your copay:
  1. Visits to your assigned primary medical provider (PMP).
  2. Preventive services.
  3. Generic prescription drugs.
 

Copay: The amount you pay for a covered health care service. You usually pay a copay when you receive the service. Copays do not count towards your deductible, but do count towards your out-of-pocket maximum.

Coinsurance: The portion, calculated as a percent (like 20%), of what you pay for a covered health care service. You pay coinsurance plus any deductibles you owe. Your health plan pays the rest.
At the time of service at the doctor or other medical service provider, you will pay your copay/coinsurance. If you have not met your deductible, a bill for the allowed amount of the service will be sent to you.

At the time of service at the doctor or other medical service provider, you will pay your copay/coinsurance. If you have not met your deductible, a bill for the allowed amount of the service will be sent to you.


Out-of-Pocket Maximum

There is an out-of-pocket limit on expenses. The out-of-pocket limit is the most you could pay during a coverage period (usually one year) for your share of the cost of covered services. This limit helps you plan for health care expenses. Premiums, balance-billed charges, health care your MDwise Marketplace plan doesn't cover and costs associated with failure to obtain pre-authorization for services are not included in the out-of-pocket limit.


Services Not Covered by MDwise Marketplace

See your policy on myMDwise for additional information about excluded services.
 

TIP: MDwise Marketplace requires you to see doctors in our network. Out-of-network health care providers are not covered unless authorized. See your handbook to learn more.