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CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam)

Field Data
Health Insurance Plan ID87416WI0070019
Health Insurance Plan Year2022
StateWisconsin
Health Insurance IssuerCommon Ground Healthcare Cooperative
Plan Formulary Description URLFormulary URL
Plan Marketing Materials URLMarketing URL
Last Plan Update DateTue, 21 Sep 2021 00:00 GMT
Last Import DateSun, 28 May 2023 07:51 GMT
Health Insurance Plan Variant87416WI0070019-06
 
Available Variants of the Health Plan

87416WI0070019-00

87416WI0070019-01

87416WI0070019-02

87416WI0070019-03

87416WI0070019-04

87416WI0070019-05

87416WI0070019-06

CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.934421424
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 94% AV Level Silver 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 URLURL
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 No
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 BrochureURL
Plan Effective Date 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 87416WI0070019-06
Plan Marketing Name CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam)
Plan Type EPO
Plan Variant Marketing Name CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $800
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $250
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $70
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $250
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $70
SBC Scenario, Treatment of a Simple Fracture, Deductible $250
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 10.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $500 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $250 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $250
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 $2000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $1000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $1,000
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 PaymentURL
URL for Summary of Benefits & CoverageURL
Wellness Program Offered No

Copay & Coinsurance of CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, 87416WI0070019

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 (87416WI0070019-06) 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 (87416WI0070019-06) have Out Of Country Coverage?

Yes. Details: Emergency Services Only

Does (87416WI0070019) Health Insurance Plan, Variant (87416WI0070019-06) have Out of Service Area Coverage?

Yes. Details: Emergency Services Only

Does (87416WI0070019) Health Insurance Plan, Variant (87416WI0070019-06) 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 Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Asthma?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for Asthma.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Heart disease?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for Heart disease.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Depression?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for Depression.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Diabetes?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for Diabetes.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for High blood pressure & high cholesterol?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for High blood pressure & high cholesterol.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Low back pain?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for Low back pain.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Pain management?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 offers Disease Management Program for Pain management.

Does CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan, Variant (87416WI0070019-06) offer Disease Management Programs for Pregnancy?

Yes, the CGHC Silver $250 Deductible CSR 94% (Dental Exam+ Allergy Testing+ Vision Exam) Health Insurance Plan Variant 87416WI0070019-06 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