Cigna Simple Choice 2000 - 99248TN0060112 Health Insurance Plan

Cigna Health and Life Insurance Company health insurance plan with the Plan ID 99248TN0060112. The plan is called Cigna Simple Choice 2000.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 99248TN0060112
Health Insurance Plan Year 2023
State Tennessee
Health Insurance Issuer Cigna Health and Life Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 99248TN0060112-00
Provider Network(s) ['TNN001']
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 Tennessee 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 - 99248TN0060112-00

Standard On Exchange Plan - 99248TN0060112-01

Open to Indians below 300% FPL - 99248TN0060112-02

Open to Indians above 300% FPL - 99248TN0060112-03

Last Plan Update Date Sat, 17 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Cigna Simple Choice 2000 Health Insurance Plan, 99248TN0060112-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

YES

25.00% Coinsurance after deductible

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

25.00% Coinsurance after deductible

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

No Charge

100.00%
Dialysis

Benefit depends on place of treatment.

YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
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

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Up to age 19. One pair of glasses (lenses and frames from the pediatric selection) per year. May receive one pair of contact lenses, including professional services, in lieu of lenses and frame benefit. May not receive contact lenses and frames/lenses in same benefit year.

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

Up to a 30 day supply at any participating pharmacy, or up to a 90 day supply at any participating 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

$15.00

100.00%
Habilitation Services

Physical Therapy limited to 20 visits per year; Occupational Therapy limited to 20 visits per year; Speech Therapy limited to 20 visits per year.

YES

$30.00

100.00%
Hearing Aids

Hearing Aid Devices - 1 Hearing Aid per ear, every 3 years Hearing Aid Exam/Evaluation - Only services necessary to select, fit and adjust the hearing aid are included in this benefit. Bone Anchored Hearing Aids - Not Covered

YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

25.00% Coinsurance after deductible

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Refer to the policy for more information regarding Diabetes.

YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

This benefit applies to Mental Health Office Visits. All other Mental Health Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

YES

$30.00

100.00%
Non-Preferred Brand Drugs

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

YES

$60.00

100.00%
Nutritional Counseling

Unlimited visits limited to Nutritional Counseling associated with Home Health and Diabetes Management. Services associated with Preventive Care are covered at the Preventive Care benefit level and treatment described in connection with a mental health or substance abuse diagnosis are covered at the Outpatient Mental Health benefit level

YES

25.00% Coinsurance after deductible

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

$60.00

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Physical Therapy limited to 20 visits per year; Occupational Therapy limited to 20 visits per year; Speech Therapy limited to 20 visits per year.

YES

25.00% Coinsurance after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Up to a 30 day supply at any participating pharmacy, or up to a 90 day supply at any participating 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

$30.00

100.00%
Prenatal and Postnatal Care
YES

25.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

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. Refer to the policy for more information about Virtual Care Services.

YES

$30.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limited to 20 visits per year for Occupational therapy and 20 visits per year for Physical therapy; same visits and coverage apply to habilitative services.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Same limits and coverage apply for habilitative services.

YES

$30.00

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

Limit: 1.0 Visit(s) per Year

Up to age 19.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$60.00

100.00%
Specialty Drugs

Including other high cost drugs. Up to a 30 day supply at any participating pharmacy, or up to a 30 day supply at any participating 90 day retail pharmacy. You pay a copayment for each 30 day supply.

YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

This benefit applies to Substance Abuse Office Visits. All other Substance Abuse Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information.

YES

$30.00

100.00%
Transplant

Lifesource Transplant Network travel benefit maximum of $10,000 per insured person per transplant. Coverage for travel expenses not available for services outside of the Lifesource Transplant Network.

YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

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

$45.00

$45.00
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

25.00% Coinsurance after deductible

100.00%

Cigna Simple Choice 2000 Health Insurance Plan Variant 99248TN0060112-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.780017779
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 Gold Off Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy
EHB Percent of Total Premium 1
First Tier Utilization 100%
Formulary ID TNF019
Formulary URL URL
HIOS Product ID 99248TN006
Import Date 12/17/2022 1:01
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 No
Is a Referral Required for Specialist? No
Issuer ID 99248
Issuer Marketplace Marketing Name Cigna Healthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID TNN001
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) 99248TN0060112-00
Plan Marketing Name Cigna Simple Choice 2000
Plan Type EPO
Plan Variant Marketing Name Cigna Simple Choice 2000
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,600
SBC Scenario, Having a Baby, Copayment $10
SBC Scenario, Having a Baby, Deductible $2,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $800
SBC Scenario, Having Diabetes, Deductible $900
SBC Scenario, Having Diabetes, Limit $20
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID TNS001
Source Name HIOS
Plan ID 99248TN0060112
State Code TN
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $4000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $2000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $2,000
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
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 Cigna Simple Choice 2000 Health Insurance Plan, 99248TN0060112

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

Frequently Asked Questions(FAQ) about Cigna Simple Choice 2000, 99248TN0060112 Health Insurance Plan, 99248TN0060112

  • Does Cigna Simple Choice 2000 Health Insurance Plan, 99248TN0060112 support Mail Ordering?

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

  • Does (99248TN0060112) Health Insurance Plan, Variant (99248TN0060112-00) offer Disease Management Programs?

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

    Does (99248TN0060112) Health Insurance Plan, Variant (99248TN0060112-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (99248TN0060112) Health Insurance Plan, Variant (99248TN0060112-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (99248TN0060112) Health Insurance Plan, Variant (99248TN0060112-00) 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 Simple Choice 2000 Health Insurance Plan, Variant (99248TN0060112-00) offer Disease Management Programs for Asthma?

    Yes, the Cigna Simple Choice 2000 Health Insurance Plan Variant 99248TN0060112-00 offers Disease Management Program for Asthma.

    Does Cigna Simple Choice 2000 Health Insurance Plan, Variant (99248TN0060112-00) offer Disease Management Programs for Heart disease?

    Yes, the Cigna Simple Choice 2000 Health Insurance Plan Variant 99248TN0060112-00 offers Disease Management Program for Heart disease.

    Does Cigna Simple Choice 2000 Health Insurance Plan, Variant (99248TN0060112-00) offer Disease Management Programs for Diabetes?

    Yes, the Cigna Simple Choice 2000 Health Insurance Plan Variant 99248TN0060112-00 offers Disease Management Program for Diabetes.

    Does Cigna Simple Choice 2000 Health Insurance Plan, Variant (99248TN0060112-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Cigna Simple Choice 2000 Health Insurance Plan Variant 99248TN0060112-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Cigna Simple Choice 2000 Health Insurance Plan, Variant (99248TN0060112-00) offer Disease Management Programs for Pregnancy?

    Yes, the Cigna Simple Choice 2000 Health Insurance Plan Variant 99248TN0060112-00 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