Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL - 85773IL0040060 Health Insurance Plan
Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 85773IL0040060. The plan is called Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 80.35% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 19.65% 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 80.01% (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 19.99% 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 | 85773IL0040060 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Illinois | ||||||||||||||||||
| Health Insurance Issuer | Quartz Health Benefit Plans Corporation | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 85773IL0040060-03 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 85773IL0040060-00 Standard On Exchange Plan - 85773IL0040060-01 |
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| Last Plan Update Date | Thu, 11 Jan 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL Health Insurance Plan, 85773IL0040060-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
Abortion services are covered at no greater cost-sharing than applicable to other pregnancy-related health services. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Accidental Dental
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Acupuncture
Limit: 12.0 Visit(s) per Benefit Period Acupuncture services are covered only when provided for the treatment of nausea or 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. Services must be obtained from licensed acupuncture providers or licensed physicians. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Allergy Testing
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
Requires Prior Authorization and must be performed at an approved health center. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
Limit: 1000.0 Dollars per Benefit Period Dental coverage through Momentum Dental's network of providers. $1000 in basic and major combined maximum benefit |
YES | 20.00% |
100.00% |
| Basic Dental Care - Child
Dental coverage through Momentum Dental's network of providers. |
YES | 30.00% |
100.00% |
| Chemotherapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
|
YES | $35.00 |
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. Characterized in the certificates as "reconstructive surgery," as it is not considered truly cosmetic. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
Copay per Day |
YES | $2,500.00 |
100.00% |
| Dental Check-Up for Children
Dental coverage through Momentum Dental's network of providers. |
YES | $0.00 |
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 | 0.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 0.00% |
100.00% |
| Emergency Room Services
|
YES | $500.00 |
$500.00 |
| Emergency Transportation/Ambulance
|
YES | 0.00% Coinsurance after deductible |
0.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 0.00% |
100.00% |
| Gender Affirming Care
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | $10.00 |
100.00% |
| Habilitation Services
Limit: 60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Treatment must be medically necessary and therapeutic and not investigational. |
YES | $50.00 Copay after deductible |
100.00% |
| Hearing Aids
Limit: 2.0 Item(s) per 2 Years Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children. |
YES | 0.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Benefit Period |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $150.00 Copay after deductible |
100.00% |
| Infertility Treatment
Limitations vary based on procedures. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $2500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 0.00% 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 | $35.00 |
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. $1000 in basic and major combined maximum benefit |
YES | 50.00% |
100.00% |
| Major Dental Care - Child
Dental coverage through Momentum Dental's network of providers. |
YES | 50.00% |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | $2500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $35.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% |
100.00% |
| Nutritional Counseling
|
YES | $35.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
When medically necessary. |
YES | 50.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $35.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Maintenance therapies not covered. |
YES | $50.00 Copay after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $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 | $35.00 |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $35.00 |
100.00% |
| Private-Duty Nursing
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 0.00% |
100.00% |
| Radiation
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Only includes benefits for mastectomy-related services. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Maintenance Therapy not covered. |
YES | $50.00 Copay after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 60.0 Visit(s) per Benefit Period Limited to 60 Visits for all therapy disciplines combined. Maintenance Therapy not covered. |
YES | $50.00 Copay after deductible |
100.00% |
| Routine Dental Services (Adult)
Dental coverage through Momentum Dental's network of providers. |
YES | $0.00 |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Visit(s) per Benefit Period 1 preventive visit covered per benefit year covered without member cost sharing; subject to applicable cost sharing thereafter. |
YES | $35.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Benefit Period |
YES | $35.00 |
100.00% |
| Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | 0.00% Coinsurance after deductible |
100.00% |
| Skilled Nursing Facility
|
YES | $2500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $70.00 |
100.00% |
| Specialty Drugs
|
YES | 60.00% |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $2500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $35.00 |
100.00% |
| Transplant
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 0.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $70.00 |
$70.00 |
| 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
Benefit provided for outpatient services and when these services are related to surgery or medical care. |
YES | $70.00 |
100.00% |
QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan Variant 85773IL0040060-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.800050494059246 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| 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, 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, Pregnancy |
| EHB Percent of Total Premium | 0.9628 |
| First Tier Utilization | 100% |
| Formulary ID | ILF009 |
| Formulary URL | URL |
| HIOS Product ID | 85773IL004 |
| Import Date | 2024-01-11 20:02:02 |
| 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 Actuarial Value | 80.35% |
| Issuer ID | 85773 |
| Issuer Marketplace Marketing Name | Quartz |
| 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 | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Family Per Person | per person not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $500 |
| 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 | No |
| National Network | No |
| Network ID | ILN002 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 85773IL0040060-03 |
| Plan Marketing Name | Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL |
| Plan Type | HMO |
| Plan Variant Marketing Name | QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $2,800 |
| 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 | $700 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS002 |
| Source Name | SERFF |
| Specialist Requiring a Referral | Except for in-network care for behavioral health and substance use disorder services, you need to obtain a referral or standing referral from your Primary Care Provider before you obtain specialty care. |
| Plan ID | 85773IL0040060 |
| State Code | IL |
| 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 |
| 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 |
Copay & Coinsurance of Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL Health Insurance Plan, 85773IL0040060
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL, 85773IL0040060 Health Insurance Plan, 85773IL0040060
-
Does Quartz Performance Gold I402 Maintenance Value Tier Rx w/Dental - IL Health Insurance Plan, 85773IL0040060 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (85773IL0040060) Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs?
Does (85773IL0040060) Health Insurance Plan, Variant (85773IL0040060-03) have Out Of Country Coverage?
Does (85773IL0040060) Health Insurance Plan, Variant (85773IL0040060-03) have Out of Service Area Coverage?
Does (85773IL0040060) Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs?
Does QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs for Asthma?
Does QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs for Heart disease?
Does QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs for Depression?
Does QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs for Diabetes?
Does QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan, Variant (85773IL0040060-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does QUARTZ PERFORMANCE GOLD I402-03 MAINTENANCE LIMITED COST SHARE VALUE TIER RX W/DENTAL - IL Health Insurance Plan, Variant (85773IL0040060-03) 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