QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED - 37833WI0380280 Health Insurance Plan
Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 37833WI0380280. The plan is called QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 79.63% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 20.37% 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 79.65% (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 20.35% 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 | 37833WI0380280 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| 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 | 37833WI0380280-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 37833WI0380280-00 Standard On Exchange Plan - 37833WI0380280-01 |
||||||||||||||||||
| Last Plan Update Date | Fri, 18 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED Health Insurance Plan, 37833WI0380280-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $30.00 |
100.00% |
| Clinical Trials
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Copay per day |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Anesthesia
|
YES | 30.00% 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 | $30.00 |
100.00% |
| Diabetes Education
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% |
100.00% |
| Emergency Room Services
|
YES | $500.00 |
$500.00 |
| Emergency Transportation/Ambulance
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 30.00% |
100.00% |
| Gender Affirming Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $5.00 |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
1 item per ear every 36 Months |
YES | 30.00% |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $30.00 |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $30.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
|
YES | $30.00 |
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 | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $40.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | $30.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period Rehabilitative services must be short term. |
YES | 30.00% Coinsurance 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 | $30.00 |
100.00% |
| Routine Eye Exam for Children
|
YES | $30.00 |
100.00% |
| Routine Foot Care
Covered from PCP for all members, at specialist only for diabetic members |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
100.00% |
| Specialty Drugs
|
YES | 60.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
The cost sharing that displays applies to outpatient office visits only. All other outpatient services may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $30.00 |
100.00% |
| Transplant
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
$60.00 |
| 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 | $60.00 |
100.00% |
QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan Variant 37833WI0380280-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7964979357097 |
| 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 |
| 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 | 0.9624 |
| First Tier Utilization | 100% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 37833WI038 |
| Import Date | 2024-10-18 01:02:01 |
| 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 | 79.63% |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WIN002 |
| Out of Country Coverage | Yes |
| Out of Country Coverage Description | Foreign claims for emergency care are subject to a maximum benefit of $20,000 per benefit year. |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 37833WI0380280-00 |
| Plan Marketing Name | QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED |
| Plan Type | HMO |
| Plan Variant Marketing Name | QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,800 |
| SBC Scenario, Having a Baby, Copayment | $200 |
| SBC Scenario, Having a Baby, Deductible | $2,500 |
| 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 | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $70 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,400 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS003 |
| Source Name | HIOS |
| Plan ID | 37833WI0380280 |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $5000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,500 |
| 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 | $14000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,000 |
| 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 |
Copay & Coinsurance of QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED Health Insurance Plan, 37833WI0380280
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED, 37833WI0380280 Health Insurance Plan, 37833WI0380280
-
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED Health Insurance Plan, 37833WI0380280 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (37833WI0380280) Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs?
Does (37833WI0380280) Health Insurance Plan, Variant (37833WI0380280-00) have Out Of Country Coverage?
Does (37833WI0380280) Health Insurance Plan, Variant (37833WI0380280-00) have Out of Service Area Coverage?
Does (37833WI0380280) Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs?
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs for Asthma?
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs for Heart disease?
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs for Depression?
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs for Diabetes?
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does QUARTZ GUNDERSEN PERFORMANCE GOLD (DENTAL & VISION) $2500 DED O/E Health Insurance Plan, Variant (37833WI0380280-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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