Illinois health plan · 2025

2025 Simplete Memorial HMO Limited Network 3500 Silver · 20129IL0330088

Health Alliance Medical Plans, Inc. offers this marketplace health insurance plan (Plan ID 20129IL0330088) so you can compare premiums, coverage levels, and provider access against other health plan insurance options. Use the modules below to decide whether this is the best health insurance plan for your household or if another insurance health plan fits better.

Metal level: Silver Plan type: HMO CSR: 94% AV Level Silver Plan Issuer: Health Alliance Medical Plans, Inc.
Telehealth Data pending HSA eligible No Dental Child Vision Adult/Child
Pay / Manage Plan View issuer site

CMS AV Calculator output: 94.29% (5.71% member share on average). Learn about AV methodology.

2025 cost summary

Key premiums & cost sharing

Rates mirror the latest CMS import (Tue, 02 Dec 2025 06:13 GMT). Personalize costs with your ZIP, age, and subsidies in the plan finder.

Monthly premium

$403 – $1581

Before subsidies

Estimate after subsidies

Deductible

N/A

N/A

See deductible details

Max out-of-pocket

$600

$1200 per group

Review MOOP rules

Office visits

Primary care $10.00
Specialist $80.00
HSA Not eligible

Drug tiers

Generic $30.00
Preferred brand $60.00

View formulary tiers

$552 / mo before subsidies

≈ $6628 per year before tax credits.

Start with this unsubsidized premium, then apply marketplace tax credits to see your final monthly payment.

  • Ideal for shoppers comparing Bronze vs. Silver budgets.
  • Update your Marketplace application to apply premium tax credits.

$1750 / mo before subsidies

≈ $21002 per year before tax credits.

Pre-subsidy rate for a couple with one dependent. Switch to Silver CSR plans if you qualify to reduce these numbers.

  • Compares well against PPO vs HMO networks when planning for childcare and telehealth needs.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$2120 / mo before subsidies

≈ $25435 per year before tax credits.

Pairs with cost-sharing reductions (CSR) when you select a Silver tier and qualify based on income.

  • Use this estimate before adding childcare, dental, or vision extras.
  • CSR Silver variants can lower deductibles dramatically for eligible incomes.
  • This Silver tier qualifies for CSR if household income is ≤250% FPL.

$1347 / mo before subsidies

≈ $16164 per year before tax credits.

Shows the combined pre-subsidy rate for two adults. Add dependents or subsidies in your application to refine it.

  • Great for households deciding between PPO and HMO networks.
  • Telehealth and HSA perks (when offered) apply to both members.
Issuer profile See benefits

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

$500.00 Copay with deductible, 30.00%

Durable Medical Equipment

30.00% Coinsurance after deductible

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Enrollment guidance

Stay on top of 2025 ACA deadlines

Open Enrollment window

Marketplace enrollment for 2025 coverage typically runs Nov 1 – Jan 15 (dates may vary slightly in Illinois). Submit changes before the deadline to avoid a coverage gap.

  • Enroll by Dec 15 for Jan 1 starts.
  • Finalize plan switches before the window closes.

Special Enrollment Periods

You can change plans mid-year if you experience a qualifying life event (move, childbirth, marriage, loss of other coverage).

  • Report the event within 60 days.
  • Keep documentation handy for Healthcare.gov or your state exchange.

CSR & subsidy reminders

Premium tax credits and cost-sharing reductions (CSR) update annually when you re-submit your marketplace application.

  • Enter accurate income to maximize Advanced Premium Tax Credits.
  • 94% AV Level Silver Plan plans like this one keep deductibles and copays lower if you qualify.

Thinking about switching?

Before you leave your current plan, compare networks, drug coverage, and total cost using the cards on this page.

  • Match provider networks so ongoing care isn’t disrupted.
  • Confirm prescriptions stay on-formulary or budget for tier changes.

Top covered benefits

How this plan handles key care scenarios

Preventive Care/Screening/Immunization

No Charge

Emergency Room Services

$500.00 Copay with deductible, 30.00%

Durable Medical Equipment

30.00% Coinsurance after deductible

Premium snapshot

Plan identifiers & filings

Track the official identifiers, documents, and filing dates tied to this plan. Open the marketing or formulary links whenever you need the latest PDF from the issuer.

Plan ID 20129IL0330088
Coverage year 2025
State Illinois
Issuer Health Alliance Medical Plans, Inc.
Formulary document Download formulary
Marketing materials View marketing kit
Variant ID 20129IL0330088-06
Available variants

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

87% AV Silver Plan · 20129IL0330088-05

94% AV Silver Plan · 20129IL0330088-06
Last plan update Wed, 09 Oct 2024 00:00 GMT
Last HealthPorta import Tue, 02 Dec 2025 06:13 GMT

Network stats

Provider access snapshot

Review the network branding plus the number of in-network clinicians we track from issuer filings. Counts update with each CMS import (Tue, 02 Dec 2025 06:13 GMT).

All providers in Illinois N/A
PCPs in Illinois N/A
Telehealth support Data pending
Nationwide providers N/A
N/A doctors statewide N/A PCPs N/A OB/GYN

Provider network(s)

['ILN007']

Providers Illinois All US states
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A

Drug coverage overview

0 drugs tracked

Inspect tier distribution plus authorization, step therapy, and quantity-limit counts sourced from HealthPorta’s formulary import.

Prior authorization Drugs
Required 0
Not Required 0
Step therapy Drugs
Required 0
Not Required 0
Quantity limits Drugs
Has Limit 0
No Limit 0

Customer highlights

What stands out for members

  • Issuer: Health Alliance Medical Plans, Inc. · Plan ID 20129IL0330088 · 2025 filing.
  • Disease management programs available: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.
  • Download the latest formulary directly from the issuer here.
  • Review marketing brochures and SBC PDFs via the issuer marketing repository.
  • Variant 20129IL0330088-06 (94% AV Silver Plan ) currently displayed.
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Benefits

Covered services & limitations

Everyday care

Office visits, preventive care, labs, imaging, and home health.

Chiropractic Care

$80.00
Tier 1 in-network $80.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 25.0 Visit(s) per Year

Spinal Manipulations Only

Exclusions: nan

Diabetes Education

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.

Exclusions: nan

Home Health Care Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Laboratory Outpatient and Professional Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Benefit provided for outpatient services and when these services are related to surgery or medical care.

Exclusions: nan

Other Practitioner Office Visit (Nurse, Physician Assistant)

$10.00
Tier 1 in-network $10.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Preventive Care/Screening/Immunization

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network 100.00%

nan

Exclusions: nan

Primary Care Visit to Treat an Injury or Illness

$10.00
Tier 1 in-network $10.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Rehabilitative Occupational and Rehabilitative Physical Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Combined PT/OT/ST all considered outpatient rehabilitation 60 visits per condition per year. Maintenance Speech Therapy is not covered.

Exclusions: nan

Rehabilitative Speech Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Combined PT/OT/ST all considered outpatient rehabilitation 60 visits per condition per year. When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s).

Exclusions: nan

Specialist Visit

$80.00
Tier 1 in-network $80.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Urgent Care Centers or Facilities

$80.00
Tier 1 in-network $80.00
Tier 2 in-network $80.00
Out-of-network $80.00

nan

Exclusions: nan

X-rays and Diagnostic Imaging

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Benefit provided for outpatient services and when these services are related to surgery or medical care.

Exclusions: nan

Hospital & urgent

Emergency room, inpatient stays, ambulance, and surgeries.

Chemotherapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Delivery and All Inpatient Services for Maternity Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Dialysis

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Durable Medical Equipment

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Emergency Room Services

$500.00 Copay with deductible, 30.00%
Tier 1 in-network $500.00 Copay with deductible, 30.00%
Tier 2 in-network $500.00 Copay with deductible, 30.00%
Out-of-network $500.00 Copay with deductible, 30.00%

nan

Exclusions: nan

Emergency Transportation/Ambulance

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 30.00% Coinsurance after deductible
Out-of-network 30.00% Coinsurance after deductible

nan

Exclusions: nan

Hospice Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Hospital Services (e.g., Hospital Stay)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Inpatient Physician and Surgical Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Inpatient Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Mental/Behavioral Health Outpatient Services

$10.00
Tier 1 in-network $10.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Facility Fee (e.g., Ambulatory Surgery Center)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Outpatient Rehabilitation Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Combined PT/OT/ST all considered outpatient rehabilitation 60 visits per condition per year Maintenance therapies not covered.

Exclusions: nan

Outpatient Surgery Physician/Surgical Services

$150.00 Copay with deductible, 30.00%
Tier 1 in-network $150.00 Copay with deductible, 30.00%
Tier 2 in-network $150.00 Copay with deductible, 40.00%
Out-of-network 100.00%

nan

Exclusions: nan

Radiation

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Skilled Nursing Facility

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Substance Abuse Disorder Inpatient Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Substance Abuse Disorder Outpatient Services

$10.00
Tier 1 in-network $10.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Transplant

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Pregnancy & family

Maternity, newborn, pediatric dental and vision extras.

Basic Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Hearing Aids

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 2.0 Item(s) per 2 Years

One hearing instrument per ear every 24 months for members, with no dollar limit for children under the age of 18. Members over the age of 18 will be subject to a $2500/instrument limit.

Exclusions: nan

Major Dental Care - Child

50.00% Coinsurance after deductible
Tier 1 in-network 50.00% Coinsurance after deductible
Tier 2 in-network 50.00% Coinsurance after deductible
Out-of-network 100.00%

Limitations vary based on procedures.

Exclusions: nan

Prenatal and Postnatal Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Benefits will be available for that care from the moment of birth up to the first 31 days, thereafter, you must add the newborn child to your Family Coverage.

Exclusions: nan

Routine Eye Exam for Children

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

nan

Exclusions: nan

Well Baby Visits and Care

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network 100.00%

nan

Exclusions: nan

Pharmacy & drugs

Generic, brand, specialty, and mail order tiers.

Generic Drugs

$30.00
Tier 1 in-network $30.00
Tier 2 in-network $30.00
Out-of-network 100.00%

All covered preventive drugs will be at $0 cost share

Exclusions: nan

Non-Preferred Brand Drugs

$100.00
Tier 1 in-network $100.00
Tier 2 in-network $100.00
Out-of-network 100.00%

nan

Exclusions: nan

Preferred Brand Drugs

$60.00
Tier 1 in-network $60.00
Tier 2 in-network $60.00
Out-of-network 100.00%

nan

Exclusions: nan

Specialty Drugs

$500.00
Tier 1 in-network $500.00
Tier 2 in-network $500.00
Out-of-network 100.00%

nan

Exclusions: nan

Wellness & extras

Vision, dental, therapies, prosthetics, weight management.

Accidental Dental

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Basic Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Dental Check-Up for Children

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network 100.00%

Limit: 1.0 Exam(s) per 6 Months

nan

Exclusions: nan

Infusion Therapy

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Major Dental Care - Adult

Coverage details pending

nan

Exclusions: nan

Nutritional Counseling

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Orthodontia - Adult

Coverage details pending

nan

Exclusions: nan

Orthodontia - Child

50.00%
Tier 1 in-network 50.00%
Tier 2 in-network 50.00%
Out-of-network 100.00%

Limitations vary based on procedures.

Exclusions: nan

Prosthetic Devices

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Covered under Durable Medical Equipment benefit

Exclusions: nan

Routine Dental Services (Adult)

Coverage details pending

nan

Exclusions: nan

Weight Loss Programs

Coverage details pending

nan

Exclusions: nan

Additional benefits

Other plan-specific services and limitations.

Abortion for Which Public Funding is Prohibited

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Acupuncture

$10.00
Tier 1 in-network $10.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 15.0 Visit(s) per Year

nan

Exclusions: nan

Allergy Testing

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Bariatric Surgery

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Cosmetic Surgery

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

Exclusions: nan

Eye Glasses for Children

No Charge
Tier 1 in-network No Charge
Tier 2 in-network No Charge
Out-of-network No Charge

Limit: 1.0 Item(s) per Year

nan

Exclusions: nan

Gender Affirming Care

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Habilitation Services

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 60.0 Visit(s) per Year

Treatment must be medically necessary and therapeutic and not investigational.

Exclusions: nan

Imaging (CT/PET Scans, MRIs)

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Benefit provided for outpatient services and when these services are related to surgery or medical care.

Exclusions: nan

Infertility Treatment

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Limit: 6.0 Procedure(s) per Year

4 Completed oocyte retrievals per plan year, if a live birth, two additional completed Oocyte Retreivals

Exclusions: nan

Long-Term/Custodial Nursing Home Care

Coverage details pending

nan

Exclusions: nan

Private-Duty Nursing

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Reconstructive Surgery

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Only includes benefits for mastectomy-related services.

Exclusions: nan

Routine Eye Exam (Adult)

$20.00
Tier 1 in-network $20.00
Tier 2 in-network $20.00
Out-of-network 100.00%

Limit: 1.0 Exam(s) per Year

nan

Exclusions: nan

Routine Foot Care

$80.00
Tier 1 in-network $80.00
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

Only covered for persons diagnosed with diabetes.

Exclusions: nan

Treatment for Temporomandibular Joint Disorders

30.00% Coinsurance after deductible
Tier 1 in-network 30.00% Coinsurance after deductible
Tier 2 in-network 40.00% Coinsurance after deductible
Out-of-network 100.00%

nan

Exclusions: nan

Variant attributes

2025 Simplete Memorial HMO Limited Network 3500 Silver · Variant 20129IL0330088-06

Plan identifiers & tier

Issuer-provided metadata for this variant.

Business Year

2025

CSR Variation Type

94% AV Level Silver Plan

HIOS Product ID

20129IL033

Metal Level

Silver

Plan ID (Standard Component ID with Variant)

20129IL0330088-06

Plan Marketing Name

2025 Simplete Memorial HMO Limited Network 3500 Silver

Plan Variant Marketing Name

2025 Simplete Memorial HMO Limited Network 3500 Silver

Issuer & service area

Issuer-provided metadata for this variant.

Issuer ID

20129

Issuer Marketplace Marketing Name

Health Alliance

Market Coverage

Individual

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

Service Area ID

ILS007

State Code

IL

URL for Summary of Benefits & Coverage

Open link

Cost sharing & actuarial values

Issuer-provided metadata for this variant.

AV Calculator Output Number

0.942926110338167

Begin Primary Care Deductible Coinsurance After Number Of Copays

0

Drug EHB Deductible, In Network (Tier 1), Default Coinsurance

0.00%

Drug EHB Deductible, In Network (Tier 2), Default Coinsurance

0.00%

Inpatient Copayment Maximum Days

0

Medical Drug Deductibles Integrated

No

Medical Drug Maximum Out of Pocket Integrated

Yes

Medical EHB Deductible, In Network (Tier 1), Default Coinsurance

30.00%

Medical EHB Deductible, In Network (Tier 2), Default Coinsurance

40.00%

SBC Scenario, Having a Baby, Coinsurance

$0

SBC Scenario, Having a Baby, Copayment

$0

SBC Scenario, Having a Baby, Deductible

$300

SBC Scenario, Having Diabetes, Coinsurance

$0

SBC Scenario, Having Diabetes, Copayment

$0

SBC Scenario, Having Diabetes, Deductible

$100

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

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

Enrollment & documents

Issuer-provided metadata for this variant.

Formulary ID

ILF011

Formulary URL

Open link

Plan Brochure

Open link

SBC Scenario, Having a Baby, Limit

$60

SBC Scenario, Having Diabetes, Limit

$20

SBC Scenario, Treatment of a Simple Fracture, Limit

$0

URL for Enrollment Payment

Open link

Additional attributes

Issuer-provided metadata for this variant.

Begin Primary Care Cost-Sharing After Number Of Visits

0

Child-Only Offering

Allows Adult and Child-Only

Composite Rating Offered

No

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), 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), 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%

Import Date

2024-10-09 20:01:46

Limited Cost Sharing Plan Variation - Estimated Advanced Payment

$0.00

HSA Eligible

No

New/Existing Plan

New

Notice Required for Pregnancy

No

Is a Referral Required for Specialist?

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), 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), 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

Plan Effective Date

2025-01-01

Plan Level Exclusions

Custodial Care, Weight Lost Programs

Plan Type

HMO

QHP/Non QHP

Both

Second Tier Utilization

40%

Source Name

SERFF

Specialist Requiring a Referral

Specialists (IN) will require a referral except OB-GYN and Optometrists

Plan ID

20129IL0330088

Unique Plan Design

No

Wellness Program Offered

No

Copay & coinsurance

Pharmacy cost sharing by tier

Drug tier Pharmacy type Copay amount Copay option Coinsurance rate Coinsurance option Mail order

Questions & answers

Frequently asked questions

How do I choose the right ACA plan in Illinois?

2025 Simplete Memorial HMO Limited Network 3500 Silver (20129IL0330088) is a Silver HMO from Health Alliance Medical Plans, Inc. in Illinois for the 2025 coverage year.

Compare it against other options with the HealthPorta plan finder to confirm premiums, deductibles, and network access fit your household.

Does 2025 Simplete Memorial HMO Limited Network 3500 Silver support telehealth or virtual urgent care?

The issuer has not published telehealth details yet. Review the Summary of Benefits and Coverage to confirm if virtual visits are included.

Is 2025 Simplete Memorial HMO Limited Network 3500 Silver HSA-eligible and does it include dental or vision coverage?

It is not marked as HSA-eligible, so confirm with the issuer before relying on tax-advantaged savings.

Dental add-ons: Child.

Vision add-ons: Adult, Child.

Does 2025 Simplete Memorial HMO Limited Network 3500 Silver support mail-order prescriptions?

Mail order coverage is not listed for this plan, so confirm with the issuer before relying on home delivery.

Which disease management programs come with 2025 Simplete Memorial HMO Limited Network 3500 Silver?

The issuer lists disease management resources for: Asthma, Depression, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs.

Is there out-of-country coverage for 2025 Simplete Memorial HMO Limited Network 3500 Silver?

Yes, limited out-of-country coverage is available. Review the Summary of Benefits for reimbursement steps. Details: Out of Network Coverage Available

Does 2025 Simplete Memorial HMO Limited Network 3500 Silver cover care outside the service area?

Yes, you have limited out-of-area coverage. See the plan documents for referral and prior authorization rules. Details: Out of Network Coverage Available

Disclaimer: Based on the Tue, 02 Dec 2025 06:13 GMT HealthPorta import from CMS issuer filings. Data is best-effort and should be validated with the issuer directly. Sources: CMS.gov and the HealthPorta Healthcare MRF API.
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