CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam) - 87416WI0060023 Health Insurance Plan
Common Ground Healthcare Cooperative health insurance plan with the Plan ID 87416WI0060023. The plan is called CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.94% (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 35.06% 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 | 87416WI0060023 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Common Ground Healthcare Cooperative | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 87416WI0060023-03 | ||||||||||||||||||
| Provider Network(s) | ENVISION NETWORK | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 87416WI0060023-00 Standard On Exchange Plan - 87416WI0060023-01 |
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| Last Plan Update Date | Wed, 20 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam) Health Insurance Plan, 87416WI0060023-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 50.00% |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $40.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 50.00% |
100.00% |
| Dialysis
|
YES | 50.00% |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% |
100.00% |
| Emergency Room Services
|
YES | $1,800.00 |
$1,800.00 |
| Emergency Transportation/Ambulance
|
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process |
YES | $35.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $100.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | 50.00% |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. |
YES | 50.00% |
100.00% |
| Hospice Services
|
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $1,075.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | $1500.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | $75.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
|
YES | $1500.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $200.00 |
100.00% |
| Outpatient Rehabilitation Services
Rehabilitative services must be short term. |
YES | $100.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $200.00 |
100.00% |
| Preferred Brand Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process. $15 Copay for Preferred Insulin for Gold and Silver plans. |
YES | $140.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| 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
Limit: 20.0 Visit(s) per Year Separate limits for OT and PT. |
YES | $100.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. |
YES | $100.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $0.00 |
100.00% |
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | $0.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 30.0 Days per Stay |
YES | $1500.00 Copay per Day |
100.00% |
| Specialist Visit
|
YES | $100.00 |
100.00% |
| Specialty Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | $1500.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $40.00 |
100.00% |
| Transplant
|
YES | 50.00% |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $200.00 |
$200.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $150.00 |
100.00% |
CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060023-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.649420430257937 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Limited Cost Sharing Plan Variation |
| 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 | $4500 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2250 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $2,250 |
| 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, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9910201811765329 |
| First Tier Utilization | 100% |
| Formulary ID | WIF013 |
| Formulary URL | URL |
| HIOS Product ID | 87416WI006 |
| Import Date | 2023-09-20 01:01:24 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 0 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| 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 | 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 | 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 Brochure | URL |
| Plan Effective Date | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 87416WI0060023-03 |
| Plan Marketing Name | CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam) |
| Plan Type | EPO |
| Plan Variant Marketing Name | CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,000 |
| SBC Scenario, Having a Baby, Copayment | $2,400 |
| 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 | $2,600 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,100 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS001 |
| Source Name | HIOS |
| Plan ID | 87416WI0060023 |
| 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 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| 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 CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam) Health Insurance Plan, 87416WI0060023
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam), 87416WI0060023 Health Insurance Plan, 87416WI0060023
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Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded - Envision Network (Vision Exam) Health Insurance Plan, 87416WI0060023 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87416WI0060023) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs?
Does (87416WI0060023) Health Insurance Plan, Variant (87416WI0060023-03) have Out Of Country Coverage?
Does (87416WI0060023) Health Insurance Plan, Variant (87416WI0060023-03) have Out of Service Area Coverage?
Does (87416WI0060023) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for Asthma?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for Heart disease?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for Depression?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for Diabetes?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for Low back pain?
Does CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060023-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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