Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 37833WI0380249. The plan is called QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.49% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.51% 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 64.30% (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 35.70% 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 | 37833WI0380249 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 37833WI0380249-00 | ||||||||||||||||||
Provider Network(s) | ['WIN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 15 Oct 2024 06:16 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 37833WI0380249-00 Standard On Exchange Plan - 37833WI0380249-01 |
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Last Plan Update Date | Fri, 28 Apr 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 15 Oct 2024 06:16 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Acupuncture
Limit: 12.0 Visit(s) per Year Acupuncture services are covered only when ? ? Provided for the treatment of nausea / vomiting when associated with pregnancy, chemotherapy, or for the treatment of chronic pain, including migraine or tension headaches, fibromyalgia, chronic neck and back pain, knee pain due to arthritis, or myofascial pain. Acupuncture is not covered for the treatment of any other conditions; ? Obtained from licensed acupuncture Providers or licensed physicians. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
Limit: 1000.0 Dollars per Benefit Period Basic and major dental can't exceed $1000 |
YES | 20.00% |
100.00% |
Basic Dental Care - Child
|
YES | 30.00% |
100.00% |
Chemotherapy
Intravenous chemotherapy is covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $40.00 |
100.00% |
Clinical Trials
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Copay per Day |
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Anesthesia
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 2.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
Diabetes Care Management
|
YES | $40.00 |
100.00% |
Diabetes Education
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 50.00% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Generic Drugs
|
YES | 50.00% Coinsurance after deductible |
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% Coinsurance after deductible |
100.00% |
Hearing Aids
1 item per ear every 36 Months |
YES | 50.00% Coinsurance after deductible |
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 | 50.00% Coinsurance after deductible |
100.00% |
Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | $60.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
Limit: 1000.0 Dollars per Benefit Period Basic and major dental can't exceed $1000 |
YES | 50.00% |
100.00% |
Major Dental Care - Child
When medically necessary. |
YES | 50.00% |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
YES | $40.00 |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
When medically necessary. |
YES | 50.00% |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% 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% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Prenatal and Postnatal Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
|
YES | $0.00, 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
100.00% |
Private-Duty Nursing
|
NO | ||
Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 50.00% 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% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Rehabilitative services must be short term. |
YES | 50.00% Coinsurance after deductible |
100.00% |
Routine Dental Services (Adult)
Limit: 2.0 Visit(s) per Year |
YES | $0.00, 0.00% |
100.00% |
Routine Eye Exam (Adult)
|
YES | $40.00 |
100.00% |
Routine Eye Exam for Children
|
YES | $40.00 |
100.00% |
Routine Foot Care
Covered from PCP for all members, at specialist only for diabetic members |
YES | $40.00 |
100.00% |
Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | 50.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $80.00 |
100.00% |
Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $80.00 |
$80.00 |
Virtual Visit
|
YES | $0.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
X-rays and Diagnostic Imaging
|
YES | $120.00 |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.643000946 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Standard Bronze Off Exchange Plan |
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 | 0.9557 |
First Tier Utilization | 100% |
Formulary ID | WIF011 |
Formulary URL | URL |
HIOS Product ID | 37833WI038 |
Import Date | 4/28/2023 4:01 |
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 | 64.49% |
Issuer ID | 37833 |
Issuer Marketplace Marketing Name | Quartz |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Expanded Bronze |
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 | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 37833WI0380249-00 |
Plan Marketing Name | QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 with Dental & Vision |
Plan Type | HMO |
Plan Variant Marketing Name | QUARTZ ONE WITH AURORA HEALTH CARE BRONZE I202 W/DENTAL & VISION DIRECT |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $300 |
SBC Scenario, Having a Baby, Copayment | $300 |
SBC Scenario, Having a Baby, Deductible | $8,000 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $400 |
SBC Scenario, Having Diabetes, Deductible | $4,300 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,300 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | WIS004 |
Source Name | HIOS |
Plan ID | 37833WI0380249 |
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 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $16000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $8000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $8,000 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | per group not applicable |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | per person not applicable |
Combined Medical and Drug EHB Deductible, Out of 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, 15 Oct 2024 06:16 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