2023 POS 2500 Elite Gold - 20129IL0340070 Health Insurance Plan

Health Alliance Medical Plans, Inc. health insurance plan with the Plan ID 20129IL0340070. The plan is called 2023 POS 2500 Elite Gold.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.58% (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 18.42% 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 20129IL0340070
Health Insurance Plan Year 2023
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 20129IL0340070-00
Provider Network(s) ['ILN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers Illinois All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 20129IL0340070-00

Standard On Exchange Plan - 20129IL0340070-01

Open to Indians below 300% FPL - 20129IL0340070-02

Open to Indians above 300% FPL - 20129IL0340070-03

Last Plan Update Date Fri, 21 Oct 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of 2023 POS 2500 Elite Gold Health Insurance Plan, 20129IL0340070-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Accidental Dental
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Acupuncture

Limit: 15.0 Visit(s) per Year

YES

$25.00

$25.00
Allergy Testing
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Bariatric Surgery
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Basic Dental Care - Adult
NO
Basic Dental Care - Child
YES

50.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Chiropractic Care

Limit: 25.0 Visit(s) per Year

Spinal Manipulations Only

YES

$50.00

$50.00
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Delivery and All Inpatient Services for Maternity Care
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Dialysis
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Durable Medical Equipment
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Emergency Room Services
YES

15.00% Coinsurance after deductible

15.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

15.00% Coinsurance after deductible

15.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

No Charge

No Charge
Gender Affirming Care
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Generic Drugs

All covered preventive drugs will be at $0 cost share

YES

$10.00

50.00% Coinsurance after deductible
Habilitation Services

Limit: 60.0 Visit(s) per Year

Treatment must be medically necessary and therapeutic and not investigational.

YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Home Health Care Services
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Hospice Services
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Imaging (CT/PET Scans, MRIs)

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Infusion Therapy
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child

Limitations vary based on procedures.

YES

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Mental/Behavioral Health Outpatient Services
YES

$25.00

50.00% Coinsurance after deductible
Non-Preferred Brand Drugs
YES

$80.00

50.00% Coinsurance after deductible
Nutritional Counseling
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Orthodontia - Adult
NO
Orthodontia - Child

Limitations vary based on procedures.

YES

50.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$25.00

50.00% Coinsurance after deductible
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Outpatient Surgery Physician/Surgical Services
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preferred Brand Drugs
YES

$40.00

50.00% Coinsurance after deductible
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Preventive Care/Screening/Immunization
YES

No Charge

50.00% Coinsurance after deductible
Primary Care Visit to Treat an Injury or Illness
YES

$25.00

50.00% Coinsurance after deductible
Private-Duty Nursing
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Prosthetic Devices

Covered under Durable Medical Equipment benefit

YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Radiation
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Reconstructive Surgery

Only includes benefits for mastectomy-related services.

YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
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

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)

Limit: 1.0 Exam(s) per Year

YES

$20.00

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

No Charge

50.00% Coinsurance after deductible
Routine Foot Care

Only covered for persons diagnosed with diabetes.

YES

$50.00

50.00% Coinsurance after deductible
Skilled Nursing Facility
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Specialist Visit
YES

$50.00

50.00% Coinsurance after deductible
Specialty Drugs
YES

$250.00

50.00% Coinsurance after deductible
Substance Abuse Disorder Inpatient Services
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Substance Abuse Disorder Outpatient Services
YES

$25.00

50.00% Coinsurance after deductible
Transplant
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Treatment for Temporomandibular Joint Disorders
YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Urgent Care Centers or Facilities
YES

$50.00

$50.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

50.00% Coinsurance after deductible
X-rays and Diagnostic Imaging

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

15.00% Coinsurance after deductible

50.00% Coinsurance after deductible

2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.815833808
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
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, 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 0.996
First Tier Utilization 100%
Formulary ID ILF002
Formulary URL URL
HIOS Product ID 20129IL034
Import Date 10/21/2022 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible No
New/Existing Plan Existing
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 15.00%
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, Out of Network, Family Per Group $10000 per group
Medical EHB Deductible, Out of Network, Family Per Person $5000 per person
Medical EHB Deductible, Out of Network, Individual $5,000
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID ILN001
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 1/1/2023
Plan ID (Standard Component ID with Variant) 20129IL0340070-00
Plan Level Exclusions Custodial Care, Weight Lost Programs
Plan Marketing Name 2023 POS 2500 Elite Gold
Plan Type POS
Plan Variant Marketing Name 2023 POS 2500 Elite Gold
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,500
SBC Scenario, Having a Baby, Copayment $60
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 $900
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $0
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
Service Area ID ILS001
Source Name SERFF
Specialist Requiring a Referral Specialists (IN) may require a referral except OB-GYN and Optometrists
Plan ID 20129IL0340070
State Code IL
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $47000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $23500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $23,500
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), Out of Network, Family Per Group $35000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $17500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $17,500
Unique Plan Design No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of 2023 POS 2500 Elite Gold Health Insurance Plan, 20129IL0340070

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about 2023 POS 2500 Elite Gold, 20129IL0340070 Health Insurance Plan, 20129IL0340070

  • Does 2023 POS 2500 Elite Gold Health Insurance Plan, 20129IL0340070 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (20129IL0340070) Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (20129IL0340070) Health Insurance Plan, Variant (20129IL0340070-00) have Out Of Country Coverage?

    Yes. Details: Out of Network Coverage Available

    Does (20129IL0340070) Health Insurance Plan, Variant (20129IL0340070-00) have Out of Service Area Coverage?

    Yes. Details: Out of Network Coverage Available

    Does (20129IL0340070) Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Asthma?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Asthma.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Heart disease?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Heart disease.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Depression?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Depression.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Diabetes?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Diabetes.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Low back pain?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Low back pain.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Pregnancy?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Pregnancy.

    Does 2023 POS 2500 Elite Gold Health Insurance Plan, Variant (20129IL0340070-00) offer Disease Management Programs for Weight loss programs?

    Yes, the 2023 POS 2500 Elite Gold Health Insurance Plan Variant 20129IL0340070-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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