Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 37833WI0380241. The plan is called QUARTZ ONE WITH ADVOCATE HEALTH CARE GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.35% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.65% 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 80.01% (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 19.99% 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 | 37833WI0380241 | ||||||||||||||||||
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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 | 37833WI0380241-00 | ||||||||||||||||||
Provider Network(s) | PREFERRED | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 37833WI0380241-00 Standard On Exchange Plan - 37833WI0380241-01 |
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Last Plan Update Date | Tue, 19 Dec 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
NO | ||
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
Limit: 1000.0 Dollars per Benefit Period Dental coverage through Momentum Dental's network of providers. Basic and major dental can't exceed $1,000. |
YES | 20.00% |
100.00% |
Basic Dental Care - Child
Dental coverage through Momentum Dental's network of providers. |
YES | 30.00% |
100.00% |
Chemotherapy
Intravenous chemotherapy is covered. |
YES | 0.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $35.00 |
100.00% |
Clinical Trials
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Copay per day |
YES | $2,500.00 |
100.00% |
Dental Anesthesia
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year Dental coverage through Momentum Dental's network of providers. |
YES | $0.00 |
100.00% |
Diabetes Care Management
|
YES | $35.00 |
100.00% |
Diabetes Education
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 0.00% |
100.00% |
Emergency Room Services
|
YES | $500.00 |
$500.00 |
Emergency Transportation/Ambulance
|
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 0.00% |
100.00% |
Gender Affirming Care
|
YES | 0.00% 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 | $50.00 Copay after deductible |
100.00% |
Hearing Aids
1 item per ear every 36 Months |
YES | 0.00% |
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 | 0.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | $150.00 Copay after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $2500.00 Copay per Day |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | $35.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
Limit: 1000.0 Dollars per Benefit Period Dental coverage through Momentum Dental's network of providers. Basic and major dental can't exceed $1,000. |
YES | 50.00% |
100.00% |
Major Dental Care - Child
Dental coverage through Momentum Dental's network of providers when medically necessary. |
YES | 50.00% |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | $2500.00 Copay per Day |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $35.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
Nutritional Counseling
|
YES | $35.00 |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Dental coverage through Momentum Dental's network of providers when medically necessary. |
YES | 50.00% |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $35.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 0.00% 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 | $50.00 Copay after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | $40.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $35.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 0.00% |
100.00% |
Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 0.00% 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 | $50.00 Copay after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Rehabilitative services must be short term. |
YES | $50.00 Copay after deductible |
100.00% |
Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year Dental coverage through Momentum Dental's network of providers. |
YES | $0.00 |
100.00% |
Routine Eye Exam (Adult)
|
YES | $35.00 |
100.00% |
Routine Eye Exam for Children
|
YES | $35.00 |
100.00% |
Routine Foot Care
Covered from PCP for all members, at specialist only for diabetic members |
YES | 0.00% Coinsurance after deductible |
100.00% |
Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | $2500.00 Copay per Day |
100.00% |
Specialist Visit
|
YES | $70.00 |
100.00% |
Specialty Drugs
|
YES | 60.00% |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | $2500.00 Copay per Day |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $35.00 |
100.00% |
Transplant
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $70.00 |
$70.00 |
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 | $70.00 |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.800050494059246 |
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 | 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 |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
EHB Percent of Total Premium | 0.9523 |
First Tier Utilization | 100% |
Formulary ID | WIF009 |
Formulary URL | URL |
HIOS Product ID | 37833WI038 |
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 | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 80.35% |
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 | 0.00% |
Medical EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
Medical EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
Medical EHB Deductible, In Network (Tier 1), Individual | $500 |
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) | 37833WI0380241-00 |
Plan Marketing Name | QUARTZ ONE WITH ADVOCATE HEALTH CARE GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL |
Plan Type | HMO |
Plan Variant Marketing Name | QUARTZ ONE WITH ADVOCATE HEALTH CARE GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $0 |
SBC Scenario, Having a Baby, Copayment | $2,800 |
SBC Scenario, Having a Baby, Deductible | $0 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $700 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $900 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | WIS002 |
Source Name | HIOS |
Plan ID | 37833WI0380241 |
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 | $18000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,000 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 01 Oct 2024 06:11 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