CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam) - 87416WI0060011 Health Insurance Plan

Common Ground Healthcare Cooperative health insurance plan with the Plan ID 87416WI0060011. The plan is called CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam).

Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 87416WI0060011
Health Insurance Plan Year 2025
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 87416WI0060011-02
Provider Network(s) PREFERRED ENVISION
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Wisconsin All US States
All 980 984
PCP 10 11
Allergy N/A N/A
OB/GYN N/A 2
Dentists 1 1
Available Variants of the Health Plan

Standard Off Exchange Plan - 87416WI0060011-00

Standard On Exchange Plan - 87416WI0060011-01

Open to Indians below 300% FPL - 87416WI0060011-02

Open to Indians above 300% FPL - 87416WI0060011-03

73% AV Silver Plan - 87416WI0060011-04

87% AV Silver Plan - 87416WI0060011-05

94% AV Silver Plan - 87416WI0060011-06

Last Plan Update Date Wed, 18 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam) Health Insurance Plan, 87416WI0060011-02

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Chiropractic Care

Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy.

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment
YES

$0.00, 0.00%

100.00%
Emergency Room Services
YES

$0.00, 0.00%

0.00%
Emergency Transportation/Ambulance
YES

$0.00, 0.00%

0.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Hospice Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00, 0.00%

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. On Cost Sharing Reduction (CSR) 73% and 87% plans, coinsurance applies once the plan?s medical deductible is met.

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services

Rehabilitative services must be short term.

YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$0.00, 0.00%

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery
YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Separate limits for OT and PT.

YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Rehabilitative services must be short term.

YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

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. On Cost Sharing Reduction (CSR) 73% and 87% plans, coinsurance applies once the plan?s medical deductible is met.

YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00, 0.00%

100.00%
Transplant
YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00, 0.00%

100.00%
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

0.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

100.00%
X-rays and Diagnostic Imaging
YES

$0.00, 0.00%

100.00%

CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2025
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Zero Cost Sharing Plan Variation
Drug EHB Deductible, Combined In/Out of Network, Family Per Group $0 per group
Drug EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Combined In/Out of Network, Individual $0
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group $0 per group
Drug EHB Deductible, Out of Network, Family Per Person $0 per person
Drug EHB Deductible, Out of Network, Individual $0
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 0.9986341170543471
First Tier Utilization 100%
Formulary ID WIF004
Formulary URL URL
HIOS Product ID 87416WI006
Import Date 2024-09-18 01:01:22
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 Actuarial Value 100.00%
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 $0 per group
Medical EHB Deductible, Combined In/Out of Network, Family Per Person $0 per person
Medical EHB Deductible, Combined In/Out of Network, Individual $0
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
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 $0 per group
Medical EHB Deductible, Out of Network, Family Per Person $0 per person
Medical EHB Deductible, Out of Network, Individual $0
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 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 87416WI0060011-02
Plan Marketing Name CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam)
Plan Type EPO
Plan Variant Marketing Name CGHC Silver $4700 NCS - Envision Network (Vision Exam)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
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 $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID WIS001
Source Name HIOS
Plan ID 87416WI0060011
State Code WI
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual $0
Unique Plan Design Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam) Health Insurance Plan, 87416WI0060011

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

Frequently Asked Questions(FAQ) about CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam), 87416WI0060011 Health Insurance Plan, 87416WI0060011

  • Does CGHC Silver $4700 Ded / $6000 Rx Ded - Envision Network (Vision Exam) Health Insurance Plan, 87416WI0060011 support Mail Ordering?

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

  • Does (87416WI0060011) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs?

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

    Does (87416WI0060011) Health Insurance Plan, Variant (87416WI0060011-02) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (87416WI0060011) Health Insurance Plan, Variant (87416WI0060011-02) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (87416WI0060011) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs?

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

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for Asthma?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for Asthma.

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for Heart disease?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for Heart disease.

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for Depression?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for Depression.

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for Diabetes?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for Diabetes.

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for Low back pain?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for Low back pain.

    Does CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan, Variant (87416WI0060011-02) offer Disease Management Programs for Pregnancy?

    Yes, the CGHC Silver $4700 NCS - Envision Network (Vision Exam) Health Insurance Plan Variant 87416WI0060011-02 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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