Cigna Simple Choice 9100 - 76763KS0010030 Health Insurance Plan
Cigna Health and Life Insurance Company health insurance plan with the Plan ID 76763KS0010030. 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 | 76763KS0010030 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Kansas | ||||||||||||||||||
| 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 | 76763KS0010030-00 | ||||||||||||||||||
| Provider Network(s) | ['KSN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 76763KS0010030-00 Standard On Exchange Plan - 76763KS0010030-01 |
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| Last Plan Update Date | Mon, 19 Dec 2022 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Cigna Simple Choice 9100 Health Insurance Plan, 76763KS0010030-00
| 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
|
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
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
Children are covered through the end of the month in which they turn 19 years of age. Limited to three pairs of pediatric collection frames and lenses every calendar year. Coverage for the second and third pair of glasses is dependent on a change in the member?s refractive state or to replace broken, damaged or lost glasses. Standard Frames must include a minimum one-year warranty. Therapeutic contact lenses are limited to a one year supply in lieu of frame and lenses. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Up to a 34-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
Includes Physical, Occupational and Speech therapies. |
YES | No Charge after deductible |
100.00% |
| Hearing Aids
Hearing Aid Devices - Not Covered (Except BAHA) Hearing Aid Exam/Evaluation - Covered at the same benefit level as Bone Anchored Hearing Aids Bone Anchored Hearing Aids - Covered-No maximum |
YES | No Charge after deductible |
100.00% |
| Home Health Care Services
Includes up to three (3) home care education visits per calendar 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
Limited to coverage for diagnosis and treatment of cause of infertility. Covered services include office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. |
YES | No Charge after deductible |
100.00% |
| 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
Refer to the policy for more information regarding Diabetes. |
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
|
YES | No Charge after deductible |
100.00% |
| Non-Preferred Brand Drugs
Up to a 34-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
|
NO | ||
| 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
Includes Physical, Occupational and Speech therapies. Speech therapy is limited to one service per day up to 90 daily services per year. |
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 34-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 after deductible. 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
|
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
|
YES | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Speech therapy is limited to one service per day up to 90 daily services per year. |
YES | No Charge after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Children are covered through the end of the month in which they turn 19 years of age. |
YES | No Charge |
100.00% |
| Routine Foot Care
Limited to coverage when systemic conditions such as metabolic, neurologic, or peripheral vascular disease exists and results in medically significant circulatory deficits or decreased sensation to the foot. Refer to the policy for more information regarding Diabetes. |
YES | No Charge after deductible |
100.00% |
| Skilled Nursing Facility
|
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 34-day supply at any Participating Pharmacy or up to a 34-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
|
YES | No Charge after deductible |
100.00% |
| Transplant
Lifesource Transplant Network travel maximum of $10,000 per insured person, 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 76763KS0010030-00 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 | KSF012 |
| Formulary URL | URL |
| HIOS Product ID | 76763KS001 |
| Import Date | 12/19/2022 20:01 |
| 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 | 76763 |
| 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 | KSN001 |
| 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) | 76763KS0010030-00 |
| 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 | KSS001 |
| Source Name | SERFF |
| Plan ID | 76763KS0010030 |
| State Code | KS |
| 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, 76763KS0010030
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Cigna Simple Choice 9100, 76763KS0010030 Health Insurance Plan, 76763KS0010030
-
Does Cigna Simple Choice 9100 Health Insurance Plan, 76763KS0010030 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (76763KS0010030) Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs?
Does (76763KS0010030) Health Insurance Plan, Variant (76763KS0010030-00) have Out Of Country Coverage?
Does (76763KS0010030) Health Insurance Plan, Variant (76763KS0010030-00) have Out of Service Area Coverage?
Does (76763KS0010030) Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs?
Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs for Asthma?
Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs for Heart disease?
Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs for Diabetes?
Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Cigna Simple Choice 9100 Health Insurance Plan, Variant (76763KS0010030-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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