QUARTZ ONE GOLD I420 VALUE TIER RX - 37833WI0510138 Health Insurance Plan

Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 37833WI0510138. The plan is called QUARTZ ONE GOLD I420 VALUE TIER RX.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.57% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.43% 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 80.87% (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 19.13% 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 37833WI0510138
Health Insurance Plan Year 2024
State Wisconsin
Health Insurance Issuer Quartz Health Benefit Plans Corporation
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 37833WI0510138-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Jul 2024 06:14 GMT).

Providers Wisconsin 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
Available Variants of the Health Plan

Standard Off Exchange Plan - 37833WI0510138-00

Standard On Exchange Plan - 37833WI0510138-01

Open to Indians below 300% FPL - 37833WI0510138-02

Open to Indians above 300% FPL - 37833WI0510138-03

Last Plan Update Date Tue, 19 Dec 2023 00:00 GMT
Last Import Date Tue, 16 Jul 2024 06:14 GMT

Benefits of QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, 37833WI0510138-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
NO
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy

Intravenous chemotherapy is covered.

YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

YES

$15.00

100.00%
Clinical Trials
YES

40.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care

Copay per Day

YES

40.00% Coinsurance after deductible

100.00%
Dental Anesthesia
YES

40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Care Management
YES

$15.00

100.00%
Diabetes Education
YES

40.00% Coinsurance after deductible

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

40.00%

100.00%
Emergency Room Services
YES

$500.00

$500.00
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

40.00%

100.00%
Gender Affirming Care
YES

40.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$10.00

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Benefit Period

limited to 20 visits per therapy discipline. Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

YES

40.00% Coinsurance after deductible

100.00%
Hearing Aids

1 item per ear every 36 Months

YES

40.00%

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less.

YES

40.00% Coinsurance after deductible

100.00%
Hospice Services
YES

40.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

$30.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$15.00

100.00%
Non-Preferred Brand Drugs
YES

50.00%

100.00%
Nutritional Counseling
YES

$15.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$15.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Benefit Period

Limited to 20 visits per therapy discipline. Rehabilitative services must be short term.

YES

40.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$45.00

100.00%
Prenatal and Postnatal Care
YES

40.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$15.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

40.00%

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

20 OT visits and 20 PT visits.

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Rehabilitative services must be short term.

YES

40.00% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

$15.00

100.00%
Routine Foot Care

Covered from PCP for all members, at specialist only for diabetic members

YES

40.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 30.0 Days per Stay

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$90.00

100.00%
Specialty Drugs
YES

60.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$15.00

100.00%
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$90.00

$90.00
Virtual Visit
YES

No Charge

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

$90.00

100.00%

QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.808696065530636
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2024
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Gold Off 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 40.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $2500 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $1250 per person
Drug EHB Deductible, In Network (Tier 1), Individual $1,250
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, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID WIF011
Formulary URL URL
HIOS Product ID 37833WI051
Import Date 2023-12-19 01:01:03
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? No
Issuer Actuarial Value 81.57%
Issuer ID 37833
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 $2000 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $1000 per person
Medical EHB Deductible, In Network (Tier 1), Individual $1,000
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 WIN001
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 2024-01-01
Plan Expiration Date 2024-12-31
Plan ID (Standard Component ID with Variant) 37833WI0510138-00
Plan Marketing Name QUARTZ ONE GOLD I420 VALUE TIER RX
Plan Type HMO
Plan Variant Marketing Name QUARTZ ONE GOLD I420 VALUE TIER RX
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $1,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $700
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,000
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 37833WI0510138
State Code WI
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 $17000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,500
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 I420 VALUE TIER RX Health Insurance Plan, 37833WI0510138

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about QUARTZ ONE GOLD I420 VALUE TIER RX, 37833WI0510138 Health Insurance Plan, 37833WI0510138

  • Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, 37833WI0510138 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (37833WI0510138) Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (37833WI0510138) Health Insurance Plan, Variant (37833WI0510138-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (37833WI0510138) Health Insurance Plan, Variant (37833WI0510138-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization

    Does (37833WI0510138) Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs for Asthma?

    Yes, the QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 offers Disease Management Program for Asthma.

    Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs for Heart disease?

    Yes, the QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 offers Disease Management Program for Heart disease.

    Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs for Depression?

    Yes, the QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 offers Disease Management Program for Depression.

    Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs for Diabetes?

    Yes, the QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 offers Disease Management Program for Diabetes.

    Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan, Variant (37833WI0510138-00) offer Disease Management Programs for Pregnancy?

    Yes, the QUARTZ ONE GOLD I420 VALUE TIER RX Health Insurance Plan Variant 37833WI0510138-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 16 Jul 2024 06:14 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