Quartz One Gold I405 - 85773IL0030022 Health Insurance Plan
Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 85773IL0030022. The plan is called Quartz One Gold I405.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 76.38% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 23.62% of the costs of all covered benefits (according to the Issuer).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 76.16% (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 23.84% 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 | 85773IL0030022 | ||||||||||||||||||
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| Health Insurance Plan Year | 2022 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Quartz Health Benefit Plans Corporation | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 85773IL0030022-01 | ||||||||||||||||||
| Provider Network(s) | ['ILN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 85773IL0030022-00 Standard On Exchange Plan - 85773IL0030022-01 |
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| Last Plan Update Date | Wed, 18 Aug 2021 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
QUARTZ ONE GOLD I405-IL Health Insurance Plan Variant 85773IL0030022-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.761622369 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2022 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange 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, 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 |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 0.99337 |
| First Tier Utilization | 100% |
| Formulary ID | ILF007 |
| Formulary URL | URL |
| HIOS Product ID | 85773IL003 |
| Import Date | 8/18/2021 20:00 |
| 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 Actuarial Value | 76.38% |
| Issuer ID | 85773 |
| Issuer Marketplace Marketing Name | Quartz |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | ILN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization |
| Plan Brochure | URL |
| Plan Effective Date | 1/1/2022 |
| Plan Expiration Date | 12/31/2022 |
| Plan ID (Standard Component ID with Variant) | 85773IL0030022-01 |
| Plan Marketing Name | Quartz One Gold I405 |
| Plan Type | HMO |
| Plan Variant Marketing Name | QUARTZ ONE GOLD I405-IL |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,200 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $2,000 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $3,000 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Except for in-network care for behavioral health and substance use disorder services, you need to obtain a referral or standing referral from your Primary Care Provider before you obtain specialty care. |
| Plan ID | 85773IL0030022 |
| State Code | IL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | per person not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $13000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6500 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,500 |
| 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 | Yes |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of Quartz One Gold I405 Health Insurance Plan, 85773IL0030022
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about Quartz One Gold I405, 85773IL0030022 Health Insurance Plan, 85773IL0030022
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Does Quartz One Gold I405 Health Insurance Plan, 85773IL0030022 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (85773IL0030022) Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs?
Does (85773IL0030022) Health Insurance Plan, Variant (85773IL0030022-01) have Out Of Country Coverage?
Does (85773IL0030022) Health Insurance Plan, Variant (85773IL0030022-01) have Out of Service Area Coverage?
Does (85773IL0030022) Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs?
Does QUARTZ ONE GOLD I405-IL Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs for Asthma?
Does QUARTZ ONE GOLD I405-IL Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs for Heart disease?
Does QUARTZ ONE GOLD I405-IL Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs for Depression?
Does QUARTZ ONE GOLD I405-IL Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs for Diabetes?
Does QUARTZ ONE GOLD I405-IL Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does QUARTZ ONE GOLD I405-IL Health Insurance Plan, Variant (85773IL0030022-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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