CGHC EPO Plus HSA Silver $4500 Deductible/0% - 87416WI0040027 Health Insurance Plan

Common Ground Healthcare Cooperative health insurance plan with the Plan ID 87416WI0040027. The plan is called CGHC EPO Plus HSA Silver $4500 Deductible/0% .

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.98% (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 29.02% 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 87416WI0040027
Health Insurance Plan Year 2022
State Wisconsin
Health Insurance Issuer Common Ground Healthcare Cooperative
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 87416WI0040027-00
Provider Network(s) ['WIN001']
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 - 87416WI0040027-00

Standard On Exchange Plan - 87416WI0040027-01

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

CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.709760599
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-Only
Composite Rating Offered No
CSR Variation Type Standard Silver Off Exchange Plan
Dental Only Plan No
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy
First Tier Utilization 100%
Formulary ID WIF022
Formulary URL URL
HIOS Product ID 87416WI004
HSA/HRA Employer Contribution No
Import Date 8/19/2021 15:35
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
New/Existing Plan New
Notice Required for Pregnancy Yes
Is a Referral Required for Specialist? No
Issuer ID 87416
Issuer Marketplace Marketing Name Common Ground Healthcare Cooperative
Market Coverage SHOP (Small Group)
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network Yes
Network ID WIN001
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Services Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Services Only
Plan Brochure URL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 87416WI0040027-00
Plan Marketing Name CGHC EPO Plus HSA Silver $4500 Deductible/0%
Plan Type EPO
Plan Variant Marketing Name CGHC EPO Plus HSA Silver $4500 Deductible/0%
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $4,500
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $2,300
SBC Scenario, Having Diabetes, Limit $20
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 WIS004
Source Name HIOS
Plan ID 87416WI0040027
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
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 $9000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $4500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $4,500
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 $9000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $4500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $4,500
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 CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, 87416WI0040027

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

Frequently Asked Questions(FAQ) about CGHC EPO Plus HSA Silver $4500 Deductible/0% , 87416WI0040027 Health Insurance Plan, 87416WI0040027

  • Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, 87416WI0040027 support Mail Ordering?

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

  • Does (87416WI0040027) Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs?

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

    Does (87416WI0040027) Health Insurance Plan, Variant (87416WI0040027-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (87416WI0040027) Health Insurance Plan, Variant (87416WI0040027-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (87416WI0040027) Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs?

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

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for Asthma?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 offers Disease Management Program for Asthma.

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for Heart disease?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 offers Disease Management Program for Heart disease.

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for Depression?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 offers Disease Management Program for Depression.

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for Diabetes?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 offers Disease Management Program for Diabetes.

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for Low back pain?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 offers Disease Management Program for Low back pain.

    Does CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan, Variant (87416WI0040027-00) offer Disease Management Programs for Pregnancy?

    Yes, the CGHC EPO Plus HSA Silver $4500 Deductible/0% Health Insurance Plan Variant 87416WI0040027-00 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