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Health Maintenance Organizations (HMO)

Wellmark Blue HMO 

This isn’t your father’s health maintenance organization (HMO). No, the Wellmark Blue HMO network covers 100 percent of hospitals and 96 percent of doctors — and provides out-state-coverage in an emergency.

Wellmark Value Health Plans and Wellmark Synergy Health Plans

These plan options are brought to you by local companies dedicated to improving the health and well-being of Iowans. Available in select Iowa counties,  Wellmark Value Health Plans work within the Mercy Health Network and its affiliated providers, while Wellmark Synergy Health Plans give you access to the network of providers who work within the University of Iowa Health Alliance. It is important to know that these are narrow networks and you may not have coverage or will have greater out-of-pocket costs when you go out-of-network.

With all our HMO plans, you choose a health care coordinator. That’s your personal or "family doctor." He or she knows your whole medical history and can recommend health care solutions to meet your unique needs. 

You see your personal doctor for routine health issues like treating the flu or preventive care like an annual physical. If you need to see a specialist, he or she may need to provide a referral. 

In an HMO network, premiums are generally lower. There is a little less flexibility — for instance if your current family doctor is not in the network you may have to pay more out-of-pocket. You may consider choosing a new one in-network to keep costs lower. But thanks to our extensive network of providers, your doctor is probably in our network, along with the best specialists in the state. 

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Wellmark Blue PPO - Preferred Provider Organization 

Do you often travel out of state? Perhaps a PPO — a preferred provider organization — is the right choice for you. The Wellmark Blue PPO network keeps you covered nearly anywhere, anytime. And when you see specialists without a referral from a primary care physician, you’re still covered. 

While you can freely choose a doctor who's out-of-network, you’ll reduce your out-of-pocket costs when you choose an in-network provider. Thanks to Blue Cross and Blue Shield’s robust national network, you’ll have access to a lot of great doctors and hospitals.

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The BlueCard® Program 

Always carry your Wellmark ID card, and don’t forget to pack it when you take a trip. Thanks to our Wellmark mobile app, it's easy to have your ID card with you wherever you go. Wellmark health plans travel well, particularly in our PPO networks. In the United States, Blue Cross and Blue Shield Plan members enjoy savings that the local Blue Plan negotiates with local doctors and hospitals. The nationwide network includes more than 90 percent of hospitals and 80 percent of doctors. And finding those providers is easy. For members in our HMO network, emergency care is always available.

Outside the United States, the BlueCard® Worldwide Program helps you access doctors and hospitals in more than 200 countries and territories. You can also get a detailed health report for a particular country, including recommended immunizations, local emergency numbers and more.

What is a Metallic Tier?

Metallic tiers help make it easy to compare plans and answer the question, How much will my plan pay vs. how much do I have to pay? They’re also called Basic Coverage Tiers. In a nutshell, the Affordable Care Act (ACA) categorizes plans for individuals and small groups in four levels:

Bronze | Silver | Gold | Platinum 

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Bronze Plan: Member pays 40%, Insurance Plan Pays 60%
Silver Plan: Member Pays 30%, Insurance Plan Pays 70%
Gold Plan: Member Pays 20%, Insurance Plan Pays 80%
Platinum Plan: Member Pays 10%. Insurance Plan Pays 90%

Coverage Manual

With a Coverage Manual of your plan, you'll find information about your specific medical and prescription benefits. This includes health benefits, costs, limitations and exceptions, and network provider information. 

You can download a coverage manual to learn more about a policy for various types of plans.

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Summary of Benefits and Coverage

Required by the Affordable Care Act, a Summary of Benefits and Coverage (SBC) is exactly as it sounds — a document that clearly and concisely explains the plan's benefits and coverage options. 

This information can help you make comparisons when you’re shopping for a plan.

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