| Field | Data |
|---|---|
| Health Insurance Plan ID | 87416WI0070019 |
| 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 |
| Last Plan Update Date | Tue, 21 Sep 2021 00:00 GMT |
| Last Import Date | Sun, 28 May 2023 07:51 GMT |
| Health Insurance Plan Variant | 87416WI0070019-01 |
| Available Variants of the Health Plan | |
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.708249799 |
| 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 and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Silver On 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 |
| EHB Percent of Total Premium | 0.9723 |
| First Tier Utilization | 100% |
| Formulary ID | WIF001 |
| Formulary URL | URL |
| HIOS Product ID | 87416WI007 |
| Import Date | 8/19/2021 15:35 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 87416 |
| Issuer Marketplace Marketing Name | Common Ground Healthcare Cooperative |
| 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 | 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) | 87416WI0070019-01 |
| Plan Marketing Name | CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) |
| Plan Type | EPO |
| Plan Variant Marketing Name | CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,900 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $3,000 |
| 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 | WIS002 |
| Source Name | HIOS |
| Plan ID | 87416WI0070019 |
| 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 | 20.00% |
| 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 |
| TEHBDedOutOfNetFamilyPerGroup | per group not applicable |
| TEHBDedOutOfNetFamilyPerPerson | 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 |
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam), 87416WI0070019 Health Insurance Plan, 87416WI0070019
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, 87416WI0070019 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87416WI0070019) Health Insurance Plan, Variant (87416WI0070019-01) 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 (87416WI0070019) Health Insurance Plan, Variant (87416WI0070019-01) have Out Of Country Coverage?
Yes. Details: Emergency Services Only
Does (87416WI0070019) Health Insurance Plan, Variant (87416WI0070019-01) have Out of Service Area Coverage?
Yes. Details: Emergency Services Only
Does (87416WI0070019) Health Insurance Plan, Variant (87416WI0070019-01) 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 HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Asthma?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Asthma.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Heart disease?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Heart disease.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Depression?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Depression.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Diabetes?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Diabetes.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for High blood pressure & high cholesterol.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Low back pain?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Low back pain.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Pain management?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Pain management.
Does CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-01) offer Disease Management Programs for Pregnancy?
Yes, the CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-01 offers Disease Management Program for Pregnancy.
Disclaimer: This is based on the import(Date: Sun, 28 May 2023 07:51 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