Cigna Health and Life Insurance Company health insurance plan with the Plan ID 76763KS0010011. The plan is called Cigna Connect 800.
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 | 76763KS0010011 | ||||||||||||||||||
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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 | 76763KS0010011-02 | ||||||||||||||||||
Provider Network(s) | ['KSN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 01 Oct 2024 06:11 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 76763KS0010011-00 Standard On Exchange Plan - 76763KS0010011-01 |
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Last Plan Update Date | Mon, 19 Dec 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 01 Oct 2024 06:11 GMT |
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
|
YES | $0.00, 0.00% |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
Chiropractic Care
|
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
Benefit depends on place of treatment |
YES | $0.00, 0.00% |
100.00% |
Durable Medical Equipment
|
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
$0.00, 0.00% |
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 | $0.00, 0.00% |
$0.00, 0.00% |
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 | $0.00, 0.00% |
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 34-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. You pay a copayment for each 34-day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
YES | $0.00, 0.00% |
100.00% |
Habilitation Services
Includes Physical, Occupational and Speech therapies. |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
100.00% |
Home Health Care Services
Includes up to three (3) home care education visits per calendar year |
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
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 | $0.00, 0.00% |
100.00% |
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
Refer to the policy for more information regarding Diabetes. |
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
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 | $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
Includes Physical, Occupational and Speech therapies. Speech therapy is limited to one service per day up to 90 daily services per year. |
YES | $0.00, 0.00% |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | $0.00, 0.00% |
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. You pay a copayment for each 34-day supply. |
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, 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Refer to the policy for more information about Virtual Care Services. |
YES | $0.00, 0.00% |
100.00% |
Private-Duty Nursing
|
YES | $0.00, 0.00% |
100.00% |
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
|
YES | $0.00, 0.00% |
100.00% |
Rehabilitative Speech Therapy
Speech therapy is limited to one service per day up to 90 daily services per year. |
YES | $0.00, 0.00% |
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 | $0.00, 0.00% |
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. |
YES | $0.00, 0.00% |
100.00% |
Skilled Nursing Facility
|
YES | $0.00, 0.00% |
100.00% |
Specialist Visit
|
YES | $0.00, 0.00% |
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 | $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% |
Tier 2 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. You pay a copayment for each 34-day supply. |
YES | $0.00, 0.00% |
100.00% |
Transplant
Lifesource Transplant Network travel maximum of $10,000 per insured person, per 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
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 | $0.00, 0.00% |
$0.00, 0.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | $0.00, 0.00% |
100.00% |
X-rays and Diagnostic Imaging
|
YES | $0.00, 0.00% |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 1 |
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 | Zero Cost Sharing Plan Variation |
Dental Only Plan | No |
Design Type | Not Applicable |
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 | KSF011 |
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 | Existing |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | No |
Issuer Actuarial Value | 100.00% |
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 | Gold |
Multiple In Network Tiers | No |
National Network | No |
Network ID | KSN002 |
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) | 76763KS0010011-02 |
Plan Marketing Name | Cigna Connect 800 |
Plan Type | EPO |
Plan Variant Marketing Name | Cigna Connect-0 |
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 | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $0 |
SBC Scenario, Having Diabetes, Deductible | $0 |
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 | $0 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | KSS002 |
Source Name | SERFF |
Plan ID | 76763KS0010011 |
State Code | KS |
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 |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, Combined In/Out of Network, Individual | $0 |
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 | $0 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Group | $0 per group |
Combined Medical and Drug EHB Deductible, Out of Network, Family Per Person | $0 per person |
Combined Medical and Drug EHB Deductible, Out of 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 |
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, 01 Oct 2024 06:11 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