2025 Simplete Memorial HMO Limited Network 2500 Gold - 20129IL0330087 Health Insurance Plan
Health Alliance Medical Plans, Inc. health insurance plan with the Plan ID 20129IL0330087. The plan is called 2025 Simplete Memorial HMO Limited Network 2500 Gold.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.11% (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 21.89% 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 | 20129IL0330087 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Health Alliance Medical Plans, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 20129IL0330087-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 20129IL0330087-00 Standard On Exchange Plan - 20129IL0330087-01 |
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| Last Plan Update Date | Wed, 09 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, 20129IL0330087-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Accidental Dental
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Limit: 15.0 Visit(s) per Year |
YES | Tier 1: $5.00 Tier 2: $40.00 |
100.00% |
| Allergy Testing
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year Spinal Manipulations Only |
YES | Tier 1: $50.00 Tier 2: $60.00 |
100.00% |
| Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Diabetes Education
Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 20.00% Coinsurance after deductible |
20.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
No Charge |
| Gender Affirming Care
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
All covered preventive drugs will be at $0 cost share |
YES | Tier 1: $10.00 Tier 2: $10.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Year Treatment must be medically necessary and therapeutic and not investigational. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 2 Years One hearing instrument per ear every 24 months for members, with no dollar limit for children under the age of 18. Members over the age of 18 will be subject to a $2500/instrument limit. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Limit: 6.0 Procedure(s) per Year 4 Completed oocyte retrievals per plan year, if a live birth, two additional completed Oocyte Retreivals |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | Tier 1: $20.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Limitations vary based on procedures. |
YES | Tier 1: 50.00% Coinsurance after deductible Tier 2: 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | Tier 1: $5.00 Tier 2: $40.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | Tier 1: $80.00 Tier 2: $80.00 |
100.00% |
| Nutritional Counseling
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Limitations vary based on procedures. |
YES | Tier 1: 50.00% Tier 2: 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | Tier 1: $5.00 Tier 2: $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Year Combined PT/OT/ST all considered outpatient rehabilitation 60 visits per condition per year Maintenance therapies not covered. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | Tier 1: $150.00 Copay with deductible, 20.00% Tier 2: $150.00 Copay with deductible, 40.00% |
100.00% |
| Preferred Brand Drugs
|
YES | Tier 1: $40.00 Tier 2: $40.00 |
100.00% |
| Prenatal and Postnatal Care
Benefits will be available for that care from the moment of birth up to the first 31 days, thereafter, you must add the newborn child to your Family Coverage. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | Tier 1: $5.00 Tier 2: $40.00 |
100.00% |
| Private-Duty Nursing
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Covered under Durable Medical Equipment benefit |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Only includes benefits for mastectomy-related services. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Year Combined PT/OT/ST all considered outpatient rehabilitation 60 visits per condition per year. Maintenance Speech Therapy is not covered. |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Year Combined PT/OT/ST all considered outpatient rehabilitation 60 visits per condition per year. When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s). |
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | Tier 1: $20.00 Tier 2: $20.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | Tier 1: $50.00 Tier 2: $60.00 |
100.00% |
| Skilled Nursing Facility
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | Tier 1: $50.00 Tier 2: $60.00 |
100.00% |
| Specialty Drugs
|
YES | Tier 1: $400.00 Tier 2: $400.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | Tier 1: $5.00 Tier 2: $40.00 |
100.00% |
| Transplant
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | Tier 1: 20.00% Coinsurance after deductible Tier 2: 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | Tier 1: $40.00 Tier 2: $40.00 |
$40.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | Tier 1: No Charge Tier 2: No Charge |
100.00% |
| X-rays and Diagnostic Imaging
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | Tier 1: $20.00 Tier 2: 40.00% Coinsurance after deductible |
100.00% |
2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan Variant 20129IL0330087-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7810785982604591 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| 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, In Network (Tier 2), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Drug EHB Deductible, In Network (Tier 2), 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, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| EHB Percent of Total Premium | 0.997 |
| First Tier Utilization | 60% |
| Formulary ID | ILF010 |
| Formulary URL | URL |
| HIOS Product ID | 20129IL033 |
| Import Date | 2024-10-09 20:01:46 |
| 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? | Yes |
| Issuer ID | 20129 |
| Issuer Marketplace Marketing Name | Health Alliance |
| 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 | $15000 per group |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | $7500 per person |
| Medical EHB Deductible, Combined In/Out of Network, Individual | $7,500 |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $10000 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $5000 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $5,000 |
| 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 | Yes |
| National Network | No |
| Network ID | ILN007 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Out of Network Coverage Available |
| Out of Service Area Coverage | Yes |
| Out of Service Area Coverage Description | Out of Network Coverage Available |
| Plan Brochure | URL |
| Plan Effective Date | 2025-01-01 |
| Plan ID (Standard Component ID with Variant) | 20129IL0330087-00 |
| Plan Level Exclusions | Custodial Care, Weight Lost Programs |
| Plan Marketing Name | 2025 Simplete Memorial HMO Limited Network 2500 Gold |
| Plan Type | HMO |
| Plan Variant Marketing Name | 2025 Simplete Memorial HMO Limited Network 2500 Gold |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $700 |
| SBC Scenario, Having Diabetes, Deductible | $900 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 40% |
| Service Area ID | ILS007 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Specialists (IN) will require a referral except OB-GYN and Optometrists |
| Plan ID | 20129IL0330087 |
| State Code | IL |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group | $30400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person | $15200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | $15,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $12000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,200 |
| 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 | No |
| URL for Enrollment Payment | URL |
| URL for Summary of Benefits & Coverage | URL |
| Wellness Program Offered | No |
Copay & Coinsurance of 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, 20129IL0330087
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about 2025 Simplete Memorial HMO Limited Network 2500 Gold, 20129IL0330087 Health Insurance Plan, 20129IL0330087
-
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, 20129IL0330087 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20129IL0330087) Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs?
Does (20129IL0330087) Health Insurance Plan, Variant (20129IL0330087-00) have Out Of Country Coverage?
Does (20129IL0330087) Health Insurance Plan, Variant (20129IL0330087-00) have Out of Service Area Coverage?
Does (20129IL0330087) Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Asthma?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Heart disease?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Depression?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Diabetes?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Low back pain?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Pregnancy?
Does 2025 Simplete Memorial HMO Limited Network 2500 Gold Health Insurance Plan, Variant (20129IL0330087-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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