Beloit One Silver I301 - 37833WI0510152 Health Insurance Plan

Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 37833WI0510152. The plan is called Beloit One Silver I301.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.79% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.21% 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 71.38% (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 28.62% 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 37833WI0510152
Health Insurance Plan Year 2022
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 37833WI0510152-00
Provider Network(s) ['WIN002']
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 Wisconsin 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 - 37833WI0510152-00

Standard On Exchange Plan - 37833WI0510152-01

Open to Indians below 300% FPL - 37833WI0510152-02

Open to Indians above 300% FPL - 37833WI0510152-03

73% AV Silver Plan - 37833WI0510152-04

87% AV Silver Plan - 37833WI0510152-05

94% AV Silver Plan - 37833WI0510152-06

Last Plan Update Date Thu, 19 Aug 2021 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.713831823
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Silver 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
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID WIF004
Formulary URL URL
HIOS Product ID 37833WI051
Import Date 8/19/2021 15:35
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 71.79%
Issuer ID 37833
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 40.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $8800 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $4400 per person
Medical EHB Deductible, In Network (Tier 1), Individual $4,400
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 Silver
Multiple In Network Tiers No
National Network No
Network ID WIN002
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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 37833WI0510152-00
Plan Marketing Name Beloit One Silver I301
Plan Type HMO
Plan Variant Marketing Name BELOIT ONE SILVER I301
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,200
SBC Scenario, Having a Baby, Copayment $100
SBC Scenario, Having a Baby, Deductible $4,400
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $2,300
SBC Scenario, Having Diabetes, Deductible $100
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 $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS002
Source Name HIOS
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 37833WI0510152
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $16300 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8150 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,150
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 Beloit One Silver I301 Health Insurance Plan, 37833WI0510152

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

Frequently Asked Questions(FAQ) about Beloit One Silver I301, 37833WI0510152 Health Insurance Plan, 37833WI0510152

  • Does Beloit One Silver I301 Health Insurance Plan, 37833WI0510152 support Mail Ordering?

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

  • Does (37833WI0510152) Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (37833WI0510152) Health Insurance Plan, Variant (37833WI0510152-00) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (37833WI0510152) Health Insurance Plan, Variant (37833WI0510152-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Room, Limited Coverage for Out of Area Student with approved Prior Authorization

    Does (37833WI0510152) Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does BELOIT ONE SILVER I301 Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs for Asthma?

    Yes, the BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 offers Disease Management Program for Asthma.

    Does BELOIT ONE SILVER I301 Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs for Heart disease?

    Yes, the BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 offers Disease Management Program for Heart disease.

    Does BELOIT ONE SILVER I301 Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs for Depression?

    Yes, the BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 offers Disease Management Program for Depression.

    Does BELOIT ONE SILVER I301 Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs for Diabetes?

    Yes, the BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 offers Disease Management Program for Diabetes.

    Does BELOIT ONE SILVER I301 Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does BELOIT ONE SILVER I301 Health Insurance Plan, Variant (37833WI0510152-00) offer Disease Management Programs for Pregnancy?

    Yes, the BELOIT ONE SILVER I301 Health Insurance Plan Variant 37833WI0510152-00 offers Disease Management Program for Pregnancy.

 

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