Quartz One Silver I307 HSA - 85773IL0030049 Health Insurance Plan

Quartz Health Benefit Plans Corporation health insurance plan with the Plan ID 85773IL0030049. The plan is called Quartz One Silver I307 HSA.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.07% (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 29.93% 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 85773IL0030049
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 85773IL0030049-00
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 - 85773IL0030049-00

Standard On Exchange Plan - 85773IL0030049-01

Open to Indians below 300% FPL - 85773IL0030049-02

Open to Indians above 300% FPL - 85773IL0030049-03

73% AV Silver Plan - 85773IL0030049-04

87% AV Silver Plan - 85773IL0030049-05

94% AV Silver Plan - 85773IL0030049-06

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 Silver I307 HSA Health Insurance Plan, 85773IL0030049-00

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

50% Coinsurance after deductible

100.00%
Accidental Dental
YES

50% 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

50% Coinsurance after deductible

100.00%
Allergy Testing
YES

50% Coinsurance after deductible

100.00%
Bariatric Surgery

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

YES

50% Coinsurance after deductible

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

50% Coinsurance after deductible

100.00%
Chiropractic Care
YES

50.00% 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

50% Coinsurance after deductible

100.00%
Delivery and All Inpatient Services for Maternity Care
YES

50% 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

50% Coinsurance after deductible

100.00%
Dialysis
YES

50% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

50% Coinsurance after deductible

100.00%
Emergency Room Services
YES

50% Coinsurance after deductible

50% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

50% Coinsurance after deductible

50% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

50% Coinsurance after deductible

100.00%
Gender Affirming Care
YES

50% Coinsurance after deductible

100.00%
Generic Drugs
YES

50% 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

50% 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

50% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Benefit Period

YES

50% Coinsurance after deductible

100.00%
Hospice Services
YES

50% Coinsurance after deductible

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

50% Coinsurance after deductible

100.00%
Infertility Treatment

Limitations vary based on procedures.

YES

50% Coinsurance after deductible

100.00%
Infusion Therapy
YES

50% Coinsurance after deductible

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

50% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

50% 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

50% 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

50% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Non-Preferred Brand Drugs
YES

50% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

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

50% 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% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

50% 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

50% 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

50.00% Coinsurance after deductible

100.00%
Private-Duty Nursing
YES

50% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

50% Coinsurance after deductible

100.00%
Radiation
YES

50% Coinsurance after deductible

100.00%
Reconstructive Surgery

Only includes benefits for mastectomy-related services.

YES

50% 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

50% Coinsurance after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Benefit Period

Maintenance Speech Therapy is not covered

YES

50% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

50.00% Coinsurance after deductible

100.00%
Routine Foot Care

Only covered for persons diagnosed with diabetes.

YES

50% Coinsurance after deductible

100.00%
Skilled Nursing Facility
YES

50% Coinsurance after deductible

100.00%
Specialist Visit
YES

50.00% Coinsurance after deductible

100.00%
Specialty Drugs
YES

50% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

50% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

50.00% Coinsurance after deductible

100.00%
Transplant
YES

50% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

50.00% Coinsurance after deductible

50.00% Coinsurance after deductible
Virtual Visits

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

YES

50.00% 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

50% Coinsurance after deductible

100.00%

QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.700663238
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 Silver 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 ILF011
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 Yes
New/Existing Plan New
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 Silver
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) 85773IL0030049-00
Plan Marketing Name Quartz One Silver I307 HSA
Plan Type HMO
Plan Variant Marketing Name QUARTZ ONE SILVER I307 HSA W/VISION-IL
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $3,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $1,200
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $3,000
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 85773IL0030049
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $6000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $3000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $3,000
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 $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 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 Silver I307 HSA Health Insurance Plan, 85773IL0030049

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

Frequently Asked Questions(FAQ) about Quartz One Silver I307 HSA, 85773IL0030049 Health Insurance Plan, 85773IL0030049

  • Does Quartz One Silver I307 HSA Health Insurance Plan, 85773IL0030049 support Mail Ordering?

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

  • Does (85773IL0030049) Health Insurance Plan, Variant (85773IL0030049-00) 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 (85773IL0030049) Health Insurance Plan, Variant (85773IL0030049-00) have Out Of Country Coverage?

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

    Does (85773IL0030049) Health Insurance Plan, Variant (85773IL0030049-00) have Out of Service Area Coverage?

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

    Does (85773IL0030049) Health Insurance Plan, Variant (85773IL0030049-00) 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 SILVER I307 HSA W/VISION-IL Health Insurance Plan, Variant (85773IL0030049-00) offer Disease Management Programs for Asthma?

    Yes, the QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 offers Disease Management Program for Asthma.

    Does QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan, Variant (85773IL0030049-00) offer Disease Management Programs for Heart disease?

    Yes, the QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 offers Disease Management Program for Heart disease.

    Does QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan, Variant (85773IL0030049-00) offer Disease Management Programs for Depression?

    Yes, the QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 offers Disease Management Program for Depression.

    Does QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan, Variant (85773IL0030049-00) offer Disease Management Programs for Diabetes?

    Yes, the QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 offers Disease Management Program for Diabetes.

    Does QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan, Variant (85773IL0030049-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan, Variant (85773IL0030049-00) offer Disease Management Programs for Pregnancy?

    Yes, the QUARTZ ONE SILVER I307 HSA W/VISION-IL Health Insurance Plan Variant 85773IL0030049-00 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