Cigna Connect 0A - 53882IL0040009 Health Insurance Plan

Cigna HealthCare of Illinois, Inc. health insurance plan with the Plan ID 53882IL0040009. The plan is called Cigna Connect 0A.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.84% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.16% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.55% (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 29.45% 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 53882IL0040009
Health Insurance Plan Year 2023
State Illinois
Health Insurance Issuer Cigna HealthCare of Illinois, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 53882IL0040009-00
Provider Network(s) ['ILN001']
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 Illinois 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 - 53882IL0040009-00

Standard On Exchange Plan - 53882IL0040009-01

Open to Indians below 300% FPL - 53882IL0040009-02

Open to Indians above 300% FPL - 53882IL0040009-03

Last Plan Update Date Thu, 23 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Cigna Connect 0A Health Insurance Plan, 53882IL0040009-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

50.00%

100.00%
Accidental Dental

Limited to treatment for accidental injury to natural teeth within six months of the accidental injury.

YES

50.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

50.00%

100.00%
Bariatric Surgery

Benefit depends on type of service provided

YES

50.00%

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00%

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Year

Includes an additional 15 visits per year for Naprapathic Services.

YES

50.00%

100.00%
Cosmetic Surgery

Cosmetic surgery for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered.

YES

50.00%

100.00%
Delivery and All Inpatient Services for Maternity Care

The per day inpatient copayment will apply for a maximum of three (3) days.

YES

$2,500.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

No Charge

100.00%
Dialysis

Benefit depends on place of treatment

YES

50.00%

100.00%
Durable Medical Equipment
YES

50.00%

100.00%
Emergency Room Services

Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.

YES

$2,000.00

$2,000.00
Emergency Transportation/Ambulance

Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.

YES

50.00%

50.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Children up to age 19, through the end of their birth month. Limit 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. One pair of contact lenses - in lieu of lenses and frames benefit, (may not receive contact lenses and frames in same benefit year).

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Cost sharing shown applies to Tier 1-Preferred Generic Drugs only. See Summary of Benefits and the policy or service agreement for more information on an additional category, Tier 2-Generic Drugs, which may apply a higher cost share. Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

YES

$3.00

100.00%
Habilitation Services

Includes unlimited Physical, Speech and Occupational Therapies.

YES

50.00%

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 2 Years

Hearing aids for adults and children, 1 per ear every 24 months. Includes bone anchored hearing aids (BAHAs) with no maximum.

YES

50.00%

100.00%
Home Health Care Services
YES

50.00%

100.00%
Hospice Services

Includes Respite care.

YES

50.00%

100.00%
Imaging (CT/PET Scans, MRIs)
YES

50.00%

100.00%
Infertility Treatment

Benefit depends on type of service provided

YES

50.00%

100.00%
Infusion Therapy
YES

50.00%

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)

The per day inpatient copayment will apply for a maximum of three (3) days.

YES

$2500.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

50.00%

100.00%
Laboratory Outpatient and Professional Services

Some laboratory tests for Diabetes are covered at no charge. Refer to the policy for more information regarding Diabetes.

YES

$50.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

The per day inpatient copayment will apply for a maximum of three (3) days.

YES

$2500.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information

YES

50.00%

100.00%
Non-Preferred Brand Drugs

Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy.

YES

50.00% Coinsurance after deductible

100.00%
Nutritional Counseling
YES

50.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$110.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

50.00%

100.00%
Outpatient Rehabilitation Services

Cardiac rehab limited to a maximum of 36 Outpatient treatment sessions within a 6 month period. Physical, Occupational and Speech Therapies are Unlimited.

YES

50.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00%

100.00%
Preferred Brand Drugs

Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

YES

$210.00

100.00%
Prenatal and Postnatal Care
YES

50.00%

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services

YES

No Charge

100.00%
Private-Duty Nursing
YES

50.00%

100.00%
Prosthetic Devices
YES

50.00%

100.00%
Radiation
YES

50.00%

100.00%
Reconstructive Surgery
YES

50.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Physical, Occupational and Speech Therapy- Unlimited. Includes medically necessary preventive physical therapy for members diagnosed with multiple sclerosis.

YES

50.00%

100.00%
Rehabilitative Speech Therapy

Unlimited Speech Therapy.

YES

50.00%

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

Children up to age 19, through the end of their birth month.

YES

No Charge

100.00%
Routine Foot Care

Services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary as part of another Covered Service.

YES

50.00%

100.00%
Skilled Nursing Facility
YES

50.00%

100.00%
Specialist Visit
YES

$110.00

100.00%
Specialty Drugs

Including other high cost drugs. Up to a 30-day supply at any designated pharmacy or up to a 90-day supply at any designated 90 day retail pharmacy.

YES

50.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services

The per day inpatient copayment will apply for a maximum of three (3) days.

YES

$2500.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services

This benefit applies to all other Outpatient Services excluding Office Visits. Substance Use Disorder Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information

YES

50.00%

100.00%
Tier 2 Generic Drugs

Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. You pay a copayment for each 30 day supply.

YES

$35.00

100.00%
Transplant

LifeSource Facility Travel Maximum: $10,000 per insured person, per transplant and a maximum reimbursement of $50 for lodging per person, per day.

YES

50.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

50.00%

100.00%
Urgent Care Centers or Facilities

Out-of-network: You pay the same level as in-network if it is an emergency as defined in your plan, otherwise Not covered.

YES

$50.00

$50.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

50.00%

100.00%

Cigna Connect 0A Health Insurance Plan Variant 53882IL0040009-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.705467594
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2023
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $10400 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $5200 per person
Drug EHB Deductible, In Network (Tier 1), Individual $5,200
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 0.998
First Tier Utilization 100%
Formulary ID ILF005
Formulary URL URL
HIOS Product ID 53882IL004
Import Date 2/23/2023 20:01
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? Yes
Issuer Actuarial Value 64.84%
Issuer ID 53882
Issuer Marketplace Marketing Name Cigna Healthcare
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 50.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Medical EHB Deductible, In Network (Tier 1), Individual $0
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID ILN001
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 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 53882IL0040009-00
Plan Marketing Name Cigna Connect 0A
Plan Type HMO
Plan Variant Marketing Name Cigna Connect 0A
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,200
SBC Scenario, Having a Baby, Copayment $5,500
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $400
SBC Scenario, Having Diabetes, Copayment $800
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $900
SBC Scenario, Treatment of a Simple Fracture, Copayment $700
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS001
Source Name SERFF
Specialist Requiring a Referral All Specialist
Plan ID 53882IL0040009
State Code IL
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
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $18200 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9100 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,100
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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Cigna Connect 0A Health Insurance Plan, 53882IL0040009

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

Frequently Asked Questions(FAQ) about Cigna Connect 0A, 53882IL0040009 Health Insurance Plan, 53882IL0040009

  • Does Cigna Connect 0A Health Insurance Plan, 53882IL0040009 support Mail Ordering?

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

  • Does (53882IL0040009) Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs?

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

    Does (53882IL0040009) Health Insurance Plan, Variant (53882IL0040009-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (53882IL0040009) Health Insurance Plan, Variant (53882IL0040009-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (53882IL0040009) Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs?

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

    Does Cigna Connect 0A Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs for Asthma?

    Yes, the Cigna Connect 0A Health Insurance Plan Variant 53882IL0040009-00 offers Disease Management Program for Asthma.

    Does Cigna Connect 0A Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs for Heart disease?

    Yes, the Cigna Connect 0A Health Insurance Plan Variant 53882IL0040009-00 offers Disease Management Program for Heart disease.

    Does Cigna Connect 0A Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs for Diabetes?

    Yes, the Cigna Connect 0A Health Insurance Plan Variant 53882IL0040009-00 offers Disease Management Program for Diabetes.

    Does Cigna Connect 0A Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Cigna Connect 0A Health Insurance Plan Variant 53882IL0040009-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Cigna Connect 0A Health Insurance Plan, Variant (53882IL0040009-00) offer Disease Management Programs for Pregnancy?

    Yes, the Cigna Connect 0A Health Insurance Plan Variant 53882IL0040009-00 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