SELECT BRONZE I205 VALUE TIER RX W/VISION DIRECT - 70373MN0040042 Health Insurance Plan
Quartz Health Plan MN Corporation health insurance plan with the Plan ID 70373MN0040042. The plan is called SELECT BRONZE I205 VALUE TIER RX W/VISION DIRECT.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.43% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.57% 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 63.59% (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 36.41% 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 | 70373MN0040042 | ||||||||||||||||||
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| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Minnesota | ||||||||||||||||||
| Health Insurance Issuer | Quartz Health Plan MN Corporation | ||||||||||||||||||
| Health Insurance Plan Variant | 70373MN0040042-01 | ||||||||||||||||||
| Provider Network(s) | ['MNN002'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 07 May 2024 06:08 GMT). |
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| Available Variants of the Health Plan | Standard On Exchange Plan - 70373MN0040042-01 |
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| Last Plan Update Date | Mon, 23 Jan 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 07 May 2024 06:08 GMT |
SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant 70373MN0040042-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.635874245 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $2000 per person | $4000 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group 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, Pregnancy, High Blood Pressure & High Cholesterol |
| EHB Percent of Total Premium | 99.71% |
| First Tier Utilization | 100% |
| Formulary ID | MNF003 |
| HIOS Product ID | 70373MN004 |
| Import Date | 1/23/2023 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 64.43% |
| Issuer ID | 70373 |
| 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 person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 50.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MNN002 |
| 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 Effective Date | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 70373MN0040042-01 |
| Plan Marketing Name | SELECT BRONZE I205 VALUE TIER RX W/VISION DIRECT |
| Plan Type | HMO |
| Plan Variant Marketing Name | SELECT BRONZE I205-01 VALUE TIER RX W/VISION |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,000 |
| 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 | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | MNS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | As a member, you have a primary care physician (PCP). Your PCP will know your medical history, serve as your first contact point for non-emergency care and coordinate your health care across the entire health care delivery system. |
| Plan ID | 70373MN0040042 |
| State Code | MN |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group 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 | $9100 per person | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of SELECT BRONZE I205 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, 70373MN0040042
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about SELECT BRONZE I205 VALUE TIER RX W/VISION DIRECT, 70373MN0040042 Health Insurance Plan, 70373MN0040042
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Does SELECT BRONZE I205 VALUE TIER RX W/VISION DIRECT Health Insurance Plan, 70373MN0040042 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (70373MN0040042) Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, High Blood Pressure & High Cholesterol
Does (70373MN0040042) Health Insurance Plan, Variant (70373MN0040042-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (70373MN0040042) Health Insurance Plan, Variant (70373MN0040042-01) have Out of Service Area Coverage?
Yes. Details: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization
Does (70373MN0040042) Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs?
Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy, High Blood Pressure & High Cholesterol
Does SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs for Asthma?
Yes, the SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant
70373MN0040042-01 offers Disease
Management Program for Asthma.
Does SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs for Heart disease?
Yes, the SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant
70373MN0040042-01 offers Disease
Management Program for Heart disease.
Does SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs for Depression?
Yes, the SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant
70373MN0040042-01 offers Disease
Management Program for Depression.
Does SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs for Diabetes?
Yes, the SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant
70373MN0040042-01 offers Disease
Management Program for Diabetes.
Does SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant
70373MN0040042-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan, Variant (70373MN0040042-01) offer Disease Management Programs for Pregnancy?
Yes, the SELECT BRONZE I205-01 VALUE TIER RX W/VISION Health Insurance Plan Variant
70373MN0040042-01 offers Disease
Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Tue, 07 May 2024 06:08 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