Find Health Plans

Select Silver I301

70373MN0040022
Silver
HMO

Select Silver I301 is a Silver HMO plan by Quartz.

IMPORTANT: You are viewing the 2022 version of Select Silver I301 70373MN0040022. You can enroll in this plan if you qualify for special enrollment until the end of 2022.

Locations

Select Silver I301 is offered in the following counties.

Plan Overview

This is a plan overview for 2022 version of Select Silver I301 70373MN0040022.
Insurer: Quartz
Network Type: HMO
Metal Type: Silver
HSA Eligible?: No
Plan ID: 70373MN0040022

Cost-Sharing Overview

Select Silver I301 offers the following cost-sharing.

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 Silver I301?

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 Silver I301 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 Silver I301 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 Silver I301 includes the following benefits at the cost sharing rates listed below.

Service In-Network
Copay / Coinsurance
Out-of-Network
Copay / Coinsurance
Limits and Explanation
Non-Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Major Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Allergy Testing
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Delivery and All Inpatient Services for Maternity Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Transplant
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Urgent Care Centers or Facilities
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Weight Loss Programs
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Accidental Dental
Covered
Excluded from In-Network MOOP: NoExcluded 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.
X-rays and Diagnostic Imaging
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Emergency Transportation/Ambulance
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Nutritional Counseling
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Orthodontia – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Durable Medical Equipment
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Mental/Behavioral Health Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Reconstructive Surgery
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Basic Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Hearing Aids
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 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.
Routine Foot Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Laboratory Outpatient and Professional Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Specialty Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Mental/Behavioral Health Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes365 Days per Episode
Primary Care Visit to Treat an Injury or Illness
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Dental Check-Up for Children
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Cosmetic Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Eye Glasses for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes1 Item(s) per Year
Radiation
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Substance Abuse Disorder Inpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes365 Days per Episode
Other Practitioner Office Visit (Nurse, Physician Assistant)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Infusion Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Rehabilitative Speech Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes20 Visit(s) per Benefit Period PA required for visits beyond 20 per benefit year.Substantially Equal
Emergency Room Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Preventive Care/Screening/Immunization
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes $300 limit per calendar year for non-network tier.
Home Health Care Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes120 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.
Basic Dental Care – Child
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No Dental Only Plan Available
Outpatient Rehabilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Benefit Period limited to 20 visits per therapy disciplineSubstantially Equal
Diabetes Education
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Well Baby Visits and Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes365 Days per Episode
Skilled Nursing Facility
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes120 Days per Episode
Hospice Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes30 Days per Episode 30 days per episode applies to respite and continuous care combined.
Preferred Brand Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Orthodontia – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Virtual First
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Applies to telehealth and virtual visits for PCP, Behavioral Heath therapy and urgent care.Additional EHB Benefit
Chemotherapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Imaging (CT/PET Scans, MRIs)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Specialist Visit
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Bariatric Surgery
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Chiropractic Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Limited to 20 visits for non-network tier
Clinical Trials
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes Additional EHB Benefit
Acupuncture
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes12 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
Abortion for Which Public Funding is Prohibited
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Substance Abuse Disorder Outpatient Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Habilitation Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes60 Visit(s) per Benefit Period limited to 20 visits per therapy disciplineSubstantially Equal
Generic Drugs
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Infertility Treatment
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes40 Visit(s) per Benefit Period 20 OT visits, 20 PT visits. PA required for visits beyond 20 per benefit year.Substantially Equal
Long-Term/Custodial Nursing Home Care
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Prosthetic Devices
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Prenatal and Postnatal Care
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Outpatient Surgery Physician/Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Dialysis
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes
Major Dental Care – Adult
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Private-Duty Nursing
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Treatment for Temporomandibular Joint Disorders
Covered
Excluded from In-Network MOOP: NoExcluded 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.
Routine Dental Services (Adult)
Not Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: No
Routine Eye Exam for Children
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes $300 limit per calendar year for non-network tier.
Inpatient Physician and Surgical Services
Covered
Excluded from In-Network MOOP: NoExcluded from Out-of-Network MOOP: Yes365 Days per Episode

Free Preventive Services

There is no copayment or coinsurance for any of the following Select Silver I301 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.

Ready to sign up for Select Silver I301?

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

Table of Contents