SELECT GOLD I410 STANDARD W/VISION DIRECT - 70373MN0040034 Health Insurance Plan
Quartz Health Plan MN Corporation health insurance plan with the Plan ID 70373MN0040034. The plan is called SELECT GOLD I410 STANDARD W/VISION DIRECT.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 70373MN0040034 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Minnesota | ||||||||||||||||||
| Health Insurance Issuer | Quartz Health Plan MN Corporation | ||||||||||||||||||
| Health Insurance Plan Variant | 70373MN0040034-01 | ||||||||||||||||||
| 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 - 70373MN0040034-01 |
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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 GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant 70373MN0040034-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.780017779 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Dental Only Plan | No |
| Design Type | Design 1 |
| 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 | MNF002 |
| 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 ID | 70373 |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Gold |
| 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) | 70373MN0040034-01 |
| Plan Marketing Name | SELECT GOLD I410 STANDARD W/VISION DIRECT |
| Plan Type | HMO |
| Plan Variant Marketing Name | SELECT GOLD I410-01 STANDARD W/VISION |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $90 |
| 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 | $1,200 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,000 |
| 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 | 70373MN0040034 |
| 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 |
| Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family | $2000 per person | $4000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
| TEHBDedOutofNetFamily | per person not applicable | per group 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 | $8700 per person | $17400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
| 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 | No |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of SELECT GOLD I410 STANDARD W/VISION DIRECT Health Insurance Plan, 70373MN0040034
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Frequently Asked Questions(FAQ) about SELECT GOLD I410 STANDARD W/VISION DIRECT, 70373MN0040034 Health Insurance Plan, 70373MN0040034
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Does SELECT GOLD I410 STANDARD W/VISION DIRECT Health Insurance Plan, 70373MN0040034 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (70373MN0040034) Health Insurance Plan, Variant (70373MN0040034-01) 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 (70373MN0040034) Health Insurance Plan, Variant (70373MN0040034-01) have Out Of Country Coverage?
No, unfortunately there
is no Out Of Country Coverage for this Health Insurance Plan
(variant of plan).
Does (70373MN0040034) Health Insurance Plan, Variant (70373MN0040034-01) have Out of Service Area Coverage?
Yes. Details: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization
Does (70373MN0040034) Health Insurance Plan, Variant (70373MN0040034-01) 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 GOLD I410-01 STANDARD W/VISION Health Insurance Plan, Variant (70373MN0040034-01) offer Disease Management Programs for Asthma?
Yes, the SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant
70373MN0040034-01 offers Disease
Management Program for Asthma.
Does SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan, Variant (70373MN0040034-01) offer Disease Management Programs for Heart disease?
Yes, the SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant
70373MN0040034-01 offers Disease
Management Program for Heart disease.
Does SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan, Variant (70373MN0040034-01) offer Disease Management Programs for Depression?
Yes, the SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant
70373MN0040034-01 offers Disease
Management Program for Depression.
Does SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan, Variant (70373MN0040034-01) offer Disease Management Programs for Diabetes?
Yes, the SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant
70373MN0040034-01 offers Disease
Management Program for Diabetes.
Does SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan, Variant (70373MN0040034-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant
70373MN0040034-01 offers Disease
Management Program for High blood pressure & high cholesterol.
Does SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan, Variant (70373MN0040034-01) offer Disease Management Programs for Pregnancy?
Yes, the SELECT GOLD I410-01 STANDARD W/VISION Health Insurance Plan Variant
70373MN0040034-01 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