Quartz One Catastrophic I101 - 85773IL0030012 Health Insurance Plan

Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 85773IL0030012. The plan is called Quartz One Catastrophic I101.

Health Insurance Plan ID 85773IL0030012
Health Insurance Plan Year 2023
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 85773IL0030012-00
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 - 85773IL0030012-00

Standard On Exchange Plan - 85773IL0030012-01

Last Plan Update Date Wed, 17 Aug 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Quartz One Catastrophic I101 Health Insurance Plan, 85773IL0030012-00

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% Coinsurance after deductible

100.00%
Accidental Dental
YES

0% Coinsurance after deductible

100.00%
Acupuncture

Limit: 12.0 Visit(s) per Benefit Period

Services are covered only when provided for the treatment of nausea / 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% Coinsurance after deductible

100.00%
Allergy Testing
YES

0% Coinsurance after deductible

100.00%
Bariatric Surgery

Requires Prior Authorization and must be performed at an approved health center.

YES

0% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

0% Coinsurance after deductible

100.00%
Chiropractic Care
YES

0.00% Coinsurance after deductible

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% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

0% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.

YES

0% Coinsurance after deductible

100.00%
Dialysis
YES

0% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

0% Coinsurance after deductible

100.00%
Emergency Room Services
YES

0% Coinsurance after deductible

0% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

0% Coinsurance after deductible

0% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

0% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

0% Coinsurance after deductible

100.00%
Generic Drugs
YES

0% Coinsurance after deductible

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

0% Coinsurance 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% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

YES

0% Coinsurance after deductible

100.00%
Hospice Services
YES

0% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)
YES

0% Coinsurance after deductible

100.00%
Infertility Treatment

Limitations vary based on procedures.

YES

0% Coinsurance after deductible

100.00%
Infusion Therapy
YES

0% Coinsurance after deductible

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

0% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

0% 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

0% Coinsurance after deductible

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services
YES

0% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

0% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

0.00% Coinsurance after deductible

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

0.00% Coinsurance after deductible

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

0% 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

0% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

0% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

0% Coinsurance after deductible

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

0% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

0.00% Coinsurance after deductible

100.00%
Private-Duty Nursing
YES

0% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

0% Coinsurance after deductible

100.00%
Radiation
YES

0% Coinsurance after deductible

100.00%
Reconstructive Surgery

Only includes benefits for mastectomy-related services.

YES

0% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Benefit Period

Limited to 20 visits for OT and 20 visits for PT

YES

0% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Maintenance Speech Therapy is not covered

YES

0% Coinsurance after deductible

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
YES

0.00% Coinsurance after deductible

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

0.00% Coinsurance after deductible

100.00%
Routine Foot Care

Only covered for persons diagnosed with diabetes.

YES

0% Coinsurance after deductible

100.00%
Skilled Nursing Facility
YES

0% Coinsurance after deductible

100.00%
Specialist Visit
YES

0.00% Coinsurance after deductible

100.00%
Specialty Drugs
YES

0% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

0% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

0.00% Coinsurance after deductible

100.00%
Transplant
YES

0% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

0% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

0.00% Coinsurance after deductible

0.00% Coinsurance after deductible
Virtual Visits

Applies to telehealth and virtual visits for PCP, Behavioral Heath therapy and urgent care.

YES

0.00% Coinsurance after deductible

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging

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

YES

0% Coinsurance after deductible

100.00%

QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 Attributes

Plan Attribute Value
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 Catastrophic 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 0.9929
First Tier Utilization 100%
Formulary ID ILF010
Formulary URL URL
HIOS Product ID 85773IL003
Import Date 8/17/2022 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 85773
Issuer Marketplace Marketing Name Quartz
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Catastrophic
Multiple In Network Tiers No
National Network No
Network ID ILN001
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 85773IL0030012-00
Plan Marketing Name Quartz One Catastrophic I101
Plan Type HMO
Plan Variant Marketing Name QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $5,400
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,800
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS001
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 85773IL0030012
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
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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 $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Quartz One Catastrophic I101 Health Insurance Plan, 85773IL0030012

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

Frequently Asked Questions(FAQ) about Quartz One Catastrophic I101, 85773IL0030012 Health Insurance Plan, 85773IL0030012

  • Does Quartz One Catastrophic I101 Health Insurance Plan, 85773IL0030012 support Mail Ordering?

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

  • Does (85773IL0030012) Health Insurance Plan, Variant (85773IL0030012-00) 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 (85773IL0030012) Health Insurance Plan, Variant (85773IL0030012-00) have Out Of Country Coverage?

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

    Does (85773IL0030012) Health Insurance Plan, Variant (85773IL0030012-00) have Out of Service Area Coverage?

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

    Does (85773IL0030012) Health Insurance Plan, Variant (85773IL0030012-00) 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 QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan, Variant (85773IL0030012-00) offer Disease Management Programs for Asthma?

    Yes, the QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 offers Disease Management Program for Asthma.

    Does QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan, Variant (85773IL0030012-00) offer Disease Management Programs for Heart disease?

    Yes, the QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 offers Disease Management Program for Heart disease.

    Does QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan, Variant (85773IL0030012-00) offer Disease Management Programs for Depression?

    Yes, the QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 offers Disease Management Program for Depression.

    Does QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan, Variant (85773IL0030012-00) offer Disease Management Programs for Diabetes?

    Yes, the QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 offers Disease Management Program for Diabetes.

    Does QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan, Variant (85773IL0030012-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan, Variant (85773IL0030012-00) offer Disease Management Programs for Pregnancy?

    Yes, the QUARTZ ONE CATASTROPHIC I101 W/VISION-IL DIRECT Health Insurance Plan Variant 85773IL0030012-00 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