Cigna Simple Choice 9100 - 74483MO0040076 Health Insurance Plan

Cigna Health and Life Insurance Company health insurance plan with the Plan ID 74483MO0040076. The plan is called Cigna Simple Choice 9100.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 59.86% (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 40.14% 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 74483MO0040076
Health Insurance Plan Year 2023
State Missouri
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 74483MO0040076-00
Provider Network(s) ['MON001']
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 Missouri 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 - 74483MO0040076-00

Standard On Exchange Plan - 74483MO0040076-01

Open to Indians below 300% FPL - 74483MO0040076-02

Open to Indians above 300% FPL - 74483MO0040076-03

Last Plan Update Date Tue, 06 Dec 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Cigna Simple Choice 9100 Health Insurance Plan, 74483MO0040076-00

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

No Charge after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Chiropractic Care

Limit: 26.0 Visit(s) per Year

YES

No Charge after deductible

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

No Charge after deductible

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

No Charge

100.00%
Dialysis

Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self-dialysis. Benefit depends on place of treatment.

YES

No Charge after deductible

100.00%
Durable Medical Equipment
YES

No Charge 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

No Charge after deductible

No Charge 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

No Charge after deductible

No Charge after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Children up to age 19, through the end of their birth month. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses for Children- One pair or one box per eye of contact lenses, including professional services ? in lieu of lenses and frame 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 Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

YES

No Charge after deductible

100.00%
Habilitation Services

Physical Therapy - 20 visits per year; Occupational Therapy- 20 visits per year; Speech Therapy- unlimited visits per year. PCP copay applies for Physical Therapy and Occupational Therapy visits.

YES

No Charge after deductible

100.00%
Hearing Aids

Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening.

YES

No Charge after deductible

100.00%
Home Health Care Services

Limit: 100.0 Visit(s) per Year

YES

No Charge after deductible

100.00%
Hospice Services
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

No Charge after deductible

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

No Charge after deductible

100.00%
Inpatient Physician and Surgical Services
YES

No Charge after deductible

100.00%
Laboratory Outpatient and Professional Services

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

YES

No Charge 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

No Charge after deductible

100.00%
Mental/Behavioral Health Outpatient Services

This benefit applies to All Other Outpatient Services excluding Office Visits. Please refer to the Specialist Office Visit benefit and to the SBC for more information.

YES

No Charge after deductible

100.00%
Non-Preferred Brand Drugs

Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy.

YES

No Charge after deductible

100.00%
Nutritional Counseling

Benefit depends on type of service provided.

YES

No Charge after deductible

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

No Charge after deductible

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

No Charge after deductible

100.00%
Outpatient Rehabilitation Services

Physical Therapy - 20 visits per year; Occupational Therapy- 20 visits per year; Speech Therapy- unlimited visits per year. Cardiac Rehabilitation -36 visits per year; Pulmonary Rehabilitation - 20 visits per year. PCP copay applies for Physical Therapy and Occupational Therapy visits.

YES

No Charge after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

No Charge 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 a Designated 90 day Retail Pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

YES

No Charge after deductible

100.00%
Prenatal and Postnatal Care
YES

No Charge after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness

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

YES

No Charge after deductible

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

Limited to Home Health Care Services

YES

No Charge after deductible

100.00%
Prosthetic Devices
YES

No Charge after deductible

100.00%
Radiation
YES

No Charge after deductible

100.00%
Reconstructive Surgery
YES

No Charge after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

20 visits for Physical Therapy and an additional 20 visits for Occupational Therapy.

YES

No Charge after deductible

100.00%
Rehabilitative Speech Therapy

Unlimited visits for speech therapy.

YES

No Charge after deductible

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

Limit: 1.0 Visit(s) per Year

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

YES

No Charge

100.00%
Routine Foot Care

Coverage is available if Medically Necessary.

YES

No Charge after deductible

100.00%
Skilled Nursing Facility

Limit: 150.0 Days per Year

YES

No Charge after deductible

100.00%
Specialist Visit
YES

No Charge after deductible

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 a Designated 90 day Retail Pharmacy.

YES

No Charge after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

No Charge after deductible

100.00%
Substance Abuse Disorder Outpatient Services

This benefit applies to All Other Outpatient Services excluding Office Visits. Please refer to the Specialist Office Visit benefit and to the SBC for more information.

YES

No Charge after deductible

100.00%
Transplant

Lifesource Travel maximum of $10,000 per transplant

YES

No Charge after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

No Charge 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

No Charge after deductible

No Charge after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

No Charge after deductible

100.00%

Cigna Simple Choice 9100 Health Insurance Plan Variant 74483MO0040076-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.598552346
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
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 MOF012
Formulary URL URL
HIOS Product ID 74483MO004
Import Date 12/6/2022 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 74483
Issuer Marketplace Marketing Name Cigna Healthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Bronze
Multiple In Network Tiers No
National Network No
Network ID MON001
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) 74483MO0040076-00
Plan Marketing Name Cigna Simple Choice 9100
Plan Type EPO
Plan Variant Marketing Name Cigna Simple Choice 9100
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $9,100
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $300
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 $2,400
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MOS001
Source Name HIOS
Plan ID 74483MO0040076
State Code MO
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 $18200 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $9100 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $9,100
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 $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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Cigna Simple Choice 9100 Health Insurance Plan, 74483MO0040076

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

Frequently Asked Questions(FAQ) about Cigna Simple Choice 9100, 74483MO0040076 Health Insurance Plan, 74483MO0040076

  • Does Cigna Simple Choice 9100 Health Insurance Plan, 74483MO0040076 support Mail Ordering?

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

  • Does (74483MO0040076) Health Insurance Plan, Variant (74483MO0040076-00) offer Disease Management Programs?

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

    Does (74483MO0040076) Health Insurance Plan, Variant (74483MO0040076-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (74483MO0040076) Health Insurance Plan, Variant (74483MO0040076-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (74483MO0040076) Health Insurance Plan, Variant (74483MO0040076-00) 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 9100 Health Insurance Plan, Variant (74483MO0040076-00) offer Disease Management Programs for Asthma?

    Yes, the Cigna Simple Choice 9100 Health Insurance Plan Variant 74483MO0040076-00 offers Disease Management Program for Asthma.

    Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (74483MO0040076-00) offer Disease Management Programs for Heart disease?

    Yes, the Cigna Simple Choice 9100 Health Insurance Plan Variant 74483MO0040076-00 offers Disease Management Program for Heart disease.

    Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (74483MO0040076-00) offer Disease Management Programs for Diabetes?

    Yes, the Cigna Simple Choice 9100 Health Insurance Plan Variant 74483MO0040076-00 offers Disease Management Program for Diabetes.

    Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (74483MO0040076-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Cigna Simple Choice 9100 Health Insurance Plan Variant 74483MO0040076-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (74483MO0040076-00) offer Disease Management Programs for Pregnancy?

    Yes, the Cigna Simple Choice 9100 Health Insurance Plan Variant 74483MO0040076-00 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