Select Gold I403 HSA
70373MN0040003
Gold
HMO
Select Gold I403 HSA is a Gold HMO plan by Quartz.
IMPORTANT: You are viewing the 2022 version of Select Gold I403 HSA 70373MN0040003. You can enroll in this plan if you qualify for special enrollment until the end of 2022.
Locations
Select Gold I403 HSA is offered in the following counties.
Plan Overview
This is a plan overview for 2022 version of Select Gold I403 HSA 70373MN0040003.
| Insurer: | Quartz |
| Network Type: | HMO |
| Metal Type: | Gold |
| HSA Eligible?: | Yes |
| Plan ID: | 70373MN0040003 |
Cost-Sharing Overview
Select Gold I403 HSA offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Select Gold I403 HSA includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | 3000 | per person | $6000 per group |
| Deductible: | 3000 | per person | $6000 per group |
| Coinsurance: | per person | $6000 per group | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Select Gold I403 HSA will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | ||
| Out-of-Network Deductible: |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | 3000 |
| Copayment: | 0 |
| Coinsurance: | 0 |
| Limit: | 0 |
| Deductible: | 0 |
| Copayment: | 0 |
| Coinsurance: | 0 |
| Limit: | 0 |
| Deductible: | 2800 |
| Copayment: | 0 |
| Coinsurance: | 0 |
| Limit: | 0 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Select Gold I403 HSA?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Select Gold I403 HSA offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, Pregnancy, High Blood Pressure & High Cholesterol |
| Notice Pregnancy: | No |
| Referral Specialist: | Yes |
| Specialist Requiring 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 Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Select Gold I403 HSA covers when you are out of the service area or out of the country.
| Out of Country Coverage: | No |
| Out of Country Coverage Description: | |
| 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 |
| National Network: | No |
Additional Benefits and Cost-Sharing
Select Gold I403 HSA includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Reconstructive Surgery Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Prenatal and Postnatal Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Abortion for Which Public Funding is Prohibited Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Emergency Room Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Inpatient Physician and Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 365 Days per Episode |
| Dental Check-Up for Children Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Nutritional Counseling Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Orthodontia – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Urgent Care Centers or Facilities Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Routine Dental Services (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 40 Visit(s) per Benefit Period 20 OT visits, 20 PT visits. PA required for visits beyond 20 per benefit year.Substantially Equal |
| Habilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 60 Visit(s) per Benefit Period limited to 20 visits per therapy disciplineSubstantially Equal |
| Preventive Care/Screening/Immunization Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | $300 limit per calendar year for non-network tier. |
| Transplant Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| X-rays and Diagnostic Imaging Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Acupuncture Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 12 Visit(s) per Year Acupuncture 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.Not EHB |
| Generic Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Outpatient Rehabilitation Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 60 Visit(s) per Benefit Period limited to 20 visits per therapy disciplineSubstantially Equal |
| Mental/Behavioral Health Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Radiation Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Delivery and All Inpatient Services for Maternity Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Basic Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Eye Glasses for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Item(s) per Year |
| Laboratory Outpatient and Professional Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Infusion Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Weight Loss Programs Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Non-Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Substance Abuse Disorder Outpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Allergy Testing Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 365 Days per Episode |
| Long-Term/Custodial Nursing Home Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Major Dental Care – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Bariatric Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Emergency Transportation/Ambulance Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Major Dental Care – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Chiropractic Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Limited to 20 visits for non-network tier |
| Home Health Care Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 120 Visit(s) per Year Must be Medically Necessary, provided as rehabilitative care, terminal care or maternity care, and ordered by a physician in a written home care plan. |
| Routine Eye Exam (Adult) Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Private-Duty Nursing Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Virtual First Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Applies to telehealth and virtual visits for PCP, Behavioral Heath therapy and urgent care.Additional EHB Benefit |
| Well Baby Visits and Care Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Treatment for Temporomandibular Joint Disorders Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Only covers procedures that are Medically Necessary. Dental services that are not required to directly treat temporomandibular disorder are not covered. |
| Durable Medical Equipment Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Rehabilitative Speech Therapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 20 Visit(s) per Benefit Period PA required for visits beyond 20 per benefit year.Substantially Equal |
| Imaging (CT/PET Scans, MRIs) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Accidental Dental Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | $300 limit per calendar year for non-network tier. Treatment/restoration must be initiated within 6 months of date of injury. Coverage is limited to initial course of treatment and/or initial restoration. Services must be provided within 24 months of date of injury. |
| Clinical Trials Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | Additional EHB Benefit |
| Specialty Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Mental/Behavioral Health Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 365 Days per Episode |
| Hearing Aids Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 1 Item(s) per 3 Years Coverage includes only external hearing aids for members 18 year old and younger who have hearing loss that is not correctible by other covered procedures. Limited to one hearing aid for each ear every three years. |
| Infertility Treatment Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Cosmetic Surgery Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Preferred Brand Drugs Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Orthodontia – Adult Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Specialist Visit Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Chemotherapy Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Diabetes Education Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Routine Eye Exam for Children Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | $300 limit per calendar year for non-network tier. |
| Dialysis Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Substance Abuse Disorder Inpatient Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 365 Days per Episode |
| Outpatient Surgery Physician/Surgical Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Basic Dental Care – Child Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | Dental Only Plan Available |
| Routine Foot Care Not Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: No | |
| Prosthetic Devices Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | |
| Hospice Services Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 30 Days per Episode 30 days per episode applies to respite and continuous care combined. |
| Skilled Nursing Facility Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes | 120 Days per Episode |
| Primary Care Visit to Treat an Injury or Illness Covered | Excluded from In-Network MOOP: No | Excluded from Out-of-Network MOOP: Yes |
Free Preventive Services
There is no copayment or coinsurance for any of the following Select Gold I403 HSA preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Ready to sign up for Select Gold I403 HSA?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904