2025 Simplete Memorial HMO Limited Network 3500 Silver - 20129IL0330088 Health Insurance Plan
Health Alliance Medical Plans, Inc. health insurance plan with the Plan ID 20129IL0330088. The plan is called 2025 Simplete Memorial HMO Limited Network 3500 Silver.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.29% (we converted the output of AV Calculator to percentage to compare with data provided by Issuer, it shows the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 5.71% of the costs of all covered benefits (according to the AV Calculator by CMS.gov). More information about AV Calculator methodology.
| Health Insurance Plan ID | 20129IL0330088 | ||||||||||||||||||
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| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Health Alliance Medical Plans, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 20129IL0330088-06 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 13 May 2025 06:05 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 20129IL0330088-00 Standard On Exchange Plan - 20129IL0330088-01 Open to Indians below 300% FPL - 20129IL0330088-02 Open to Indians above 300% FPL - 20129IL0330088-03 73% AV Silver Plan - 20129IL0330088-04 |
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| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 13 May 2025 06:05 GMT |
2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan Variant 20129IL0330088-06 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.942926110338167 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | 94% AV Level Silver Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.997 |
| First Tier Utilization | 60% |
| Formulary ID | ILF011 |
| Formulary URL | URL |
| HIOS Product ID | 20129IL033 |
| Import Date | 2024-10-09 20:01:46 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer ID | 20129 |
| Issuer Marketplace Marketing Name | Health Alliance |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Group | $1800 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $900 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $900 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $600 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $300 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $300 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $1200 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $600 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $600 |
| Medical EHB Deductible, Out of Network, Family Per Group | per group not applicable |
| Medical EHB Deductible, Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Silver |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | ILN007 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of Network Coverage Available |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Network Coverage Available |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 20129IL0330088-06 |
| Plan Level Exclusions | Custodial Care, Weight Lost Programs |
| Plan Marketing Name | 2025 Simplete Memorial HMO Limited Network 3500 Silver |
| Plan Type | HMO |
| Plan Variant Marketing Name | 2025 Simplete Memorial HMO Limited Network 3500 Silver |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $300 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $0 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 40% |
| Service Area ID | ILS007 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Specialists (IN) will require a referral except OB-GYN and Optometrists |
| Plan ID | 20129IL0330088 |
| State Code | IL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $3000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $1500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $1,500 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $1200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $600 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $600 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $1800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $900 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, 20129IL0330088
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about 2025 Simplete Memorial HMO Limited Network 3500 Silver, 20129IL0330088 Health Insurance Plan, 20129IL0330088
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Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, 20129IL0330088 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20129IL0330088) Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs?
Does (20129IL0330088) Health Insurance Plan, Variant (20129IL0330088-06) have Out Of Country Coverage?
Does (20129IL0330088) Health Insurance Plan, Variant (20129IL0330088-06) have Out of Service Area Coverage?
Does (20129IL0330088) Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Asthma?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Heart disease?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Depression?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Diabetes?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for High blood pressure & high cholesterol?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Low back pain?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Pregnancy?
Does 2025 Simplete Memorial HMO Limited Network 3500 Silver Health Insurance Plan, Variant (20129IL0330088-06) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 13 May 2025 06:05 GMT) of the data from Healthcare Issuers listed by CMS. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. Source: CMS.gov, HealthPorta HEALTHCARE MRF API