Common Ground Healthcare Cooperative health insurance plan with the Plan ID 87416WI0070019. The plan is called CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.82% (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 29.18% 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 | 87416WI0070019 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
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 | 87416WI0070019-03 | ||||||||||||||||||
Provider Network(s) | ['WIN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 27 Aug 2024 05:58 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 87416WI0070019-00 Standard On Exchange Plan - 87416WI0070019-01 Open to Indians below 300% FPL - 87416WI0070019-02 Open to Indians above 300% FPL - 87416WI0070019-03 73% AV Silver Plan - 87416WI0070019-04 |
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Last Plan Update Date | Thu, 19 Aug 2021 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 27 Aug 2024 05:58 GMT |
Plan Attribute | Value |
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AV Calculator Output Number | 0.708249799 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2022 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | Limited Cost Sharing Plan Variation |
Dental Only Plan | No |
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 | 0.9723 |
First Tier Utilization | 100% |
Formulary ID | WIF001 |
Formulary URL | URL |
HIOS Product ID | 87416WI007 |
Import Date | 8/19/2021 15:35 |
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 | 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 | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Silver |
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 | 1/1/2022 |
Plan Expiration Date | 12/31/2022 |
Plan ID (Standard Component ID with Variant) | 87416WI0070019-03 |
Plan Marketing Name | CGHC HSA Silver $3000 Deductible (Dental Exam+ Allergy Testing+ Vision Exam) |
Plan Type | EPO |
Plan Variant Marketing Name | CGHC Silver $3000 Deductible LCS (Dental Exam+ Allergy Testing+ Vision Exam) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,900 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $3,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $200 |
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 | $2,800 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | WIS002 |
Source Name | HIOS |
Plan ID | 87416WI0070019 |
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 |
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 | 20.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $6000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,000 |
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 | $12000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $6000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $6,000 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 27 Aug 2024 05:58 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