Cigna HealthCare of Illinois, Inc. health insurance plan with the Plan ID 53882IL0040039. The plan is called Cigna Plus Northwestern Medicine 0 ($0 Tier 1 Rx, $0 Medical Deductible).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.07% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.93% 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 89.01% (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 10.99% 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 | 53882IL0040039 | ||||||||||||||||||
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Health Insurance Plan Year | 2022 | ||||||||||||||||||
State | Illinois | ||||||||||||||||||
Health Insurance Issuer | Cigna HealthCare of Illinois, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 53882IL0040039-05 | ||||||||||||||||||
Provider Network(s) | ['ILN002'] | ||||||||||||||||||
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 - 53882IL0040039-00 Standard On Exchange Plan - 53882IL0040039-01 Open to Indians below 300% FPL - 53882IL0040039-02 Open to Indians above 300% FPL - 53882IL0040039-03 73% AV Silver Plan - 53882IL0040039-04 |
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Last Plan Update Date | Thu, 09 Dec 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 | 0.890070205 |
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 | 87% AV Level Silver Plan |
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 | 30.00% |
Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1000 per group |
Drug EHB Deductible, In Network (Tier 1), Family Per Person | $500 per person |
Drug EHB Deductible, In Network (Tier 1), Individual | $500 |
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 |
Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
EHB Percent of Total Premium | 0.998 |
First Tier Utilization | 100% |
Formulary ID | ILF011 |
Formulary URL | URL |
HIOS Product ID | 53882IL004 |
Import Date | 12/9/2021 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? | Yes |
Issuer Actuarial Value | 87.07% |
Issuer ID | 53882 |
Issuer Marketplace Marketing Name | Cigna Healthcare |
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 | 30.00% |
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 | Silver |
Multiple In Network Tiers | No |
National Network | No |
Network ID | ILN002 |
Out of Country Coverage | Yes |
Out of Country Coverage Description | Emergency Only |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Emergency Only |
Plan Brochure | URL |
Plan Effective Date | 1/1/2022 |
Plan Expiration Date | 12/31/2022 |
Plan ID (Standard Component ID with Variant) | 53882IL0040039-05 |
Plan Marketing Name | Cigna Plus Northwestern Medicine 0 ($0 Tier 1 Rx, $0 Medical Deductible) |
Plan Type | HMO |
Plan Variant Marketing Name | Cigna Plus Northwestern Medicine 0-3 ($0 Tier 1 Rx, $0 Medical Deductible) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,900 |
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 | $300 |
SBC Scenario, Having Diabetes, Copayment | $400 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $600 |
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 | ILS002 |
Source Name | SERFF |
Specialist Requiring a Referral | All Specialists |
Plan ID | 53882IL0040039 |
State Code | IL |
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 | $5800 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $2900 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $2,900 |
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 | 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, 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