SELECT GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL - 70373MN0050032 Health Insurance Plan
Quartz Health Plan MN Corporation health insurance plan with the Plan ID 70373MN0050032. The plan is called SELECT GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL.
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 | 70373MN0050032 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Minnesota | ||||||||||||||||||
| Health Insurance Issuer | Quartz Health Plan MN Corporation | ||||||||||||||||||
| Health Insurance Plan Variant | 70373MN0050032-03 | ||||||||||||||||||
| Provider Network(s) | ['MNN001'] | ||||||||||||||||||
| 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 On Exchange Plan - 70373MN0050032-01 |
||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan Variant 70373MN0050032-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.800050494 |
| 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 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 | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $0 per person | $0 per group |
| Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| 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 | Pregnancy, High Blood Pressure & High Cholesterol, Depression, Diabetes, Heart Disease, Asthma |
| EHB Percent of Total Premium | 96% |
| First Tier Utilization | 100% |
| Formulary ID | MNF009 |
| HIOS Product ID | 70373MN005 |
| Import Date | 2/12/2024 |
| HSA Eligible | No |
| IsItANewPlan | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 80.35% |
| 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 | 0.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $500 per person | $1000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $500 |
| 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 | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | MNN001 |
| 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 | 1/1/2024 |
| Plan Expiration Date | 12/31/2024 |
| Plan ID (Standard Component ID with Variant) | 70373MN0050032-03 |
| Plan Marketing Name | SELECT GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL |
| Plan Type | HMO |
| Plan Variant Marketing Name | SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL |
| 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 | $900 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| 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 | 70373MN0050032 |
| 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 | $9000 per person | $18000 per group |
| 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 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 GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, 70373MN0050032
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about SELECT GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL, 70373MN0050032 Health Insurance Plan, 70373MN0050032
-
Does SELECT GOLD I402 MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, 70373MN0050032 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (70373MN0050032) Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs?
Does (70373MN0050032) Health Insurance Plan, Variant (70373MN0050032-03) have Out Of Country Coverage?
Does (70373MN0050032) Health Insurance Plan, Variant (70373MN0050032-03) have Out of Service Area Coverage?
Does (70373MN0050032) Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs?
Does SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs for Asthma?
Does SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs for Heart disease?
Does SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs for Depression?
Does SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs for Diabetes?
Does SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, Variant (70373MN0050032-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does SELECT GOLD I402-03 LIMITED COST SHARE MAINTENANCE VALUE TIER RX W/DENTAL Health Insurance Plan, Variant (70373MN0050032-03) 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