Cigna Health and Life Insurance Company health insurance plan with the Plan ID 41921VA0020069. The plan is called Cigna Simple Choice 2000.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.00% (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 22.00% 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 | 41921VA0020069 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Virginia | ||||||||||||||||||
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 | 41921VA0020069-03 | ||||||||||||||||||
Provider Network(s) | ['VAN001'] | ||||||||||||||||||
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 - 41921VA0020069-00 Standard On Exchange Plan - 41921VA0020069-01 |
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Last Plan Update Date | Wed, 14 Dec 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 27 Aug 2024 05:58 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Treatment must begin within 12 months of injury. Dental appliances required to diagnose or treat an accidental injury to the teeth, and the repair of dental appliances damaged as a result of accidental injury to the jaw, mouth or face, are also covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 30.0 Visit(s) per Year Chiropractic/Osteopathic and Manipulation Therapy. Visit limit applies separately to habilitative and rehabilitative services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
|
NO | ||
Diabetes Education
Including nutritional therapy |
YES | No Charge |
100.00% |
Dialysis
Benefit depends on place of treatment. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Includes orthotics and cochlear implants. |
YES | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
Emergency Transportation/Ambulance
Ground, Air and Water transport. 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 | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year Limited to 1 pair of glasses (lenses and frames from pediatric selection) per calendar year. Therapeutic Contact Lenses are covered for a one year supply, regardless of the contact lens type, including professional services, in lieu of frame and lenses (may not receive contact lenses and frames in same benefit year). Elective Contact Lenses are covered for one pair or a single purchase of a supply of contact lenses in lieu of lenses and frame benefit (may not receive contact lenses and frames in same benefit year), including the professional services. |
YES | No Charge |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. You pay a copayment for each 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
YES | $15.00 |
100.00% |
Habilitation Services
Physical Therapy and Occupational Therapy - 30 visits combined per year, Speech Therapy and Speech-Language Pathology (SLP) Services - 30 visits per year, Chiropractic/Osteopathic and Manipulation Therapy - 30 visits per year. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | $30.00 |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
Hospice Services
Coverage for custodial care, inpatient respite care, home health aide services, and homemaker services given by or under the supervision of a registered nurse. Bereavement services, both before and after the member?s death. Services for the surviving members of the immediate family for up to one year after the member?s death. Immediate family means all family members covered by this policy. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Infertility Treatment
|
NO | ||
Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
Inpatient Room and Board, Lab and X-ray, Operating Room, etc. Out-of-Network: Emergency Services covered at In-Network cost share until transferable to an In-Network Hospital; if transferred to a Non-Participating Hospital services will no longer be covered and you will be responsible for 100% of the charges. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
Refer to the policy for more information regarding Diabetes. |
YES | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. This benefit applies to Mental Health Office Visits. All other Mental Health Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information. |
YES | $30.00 |
100.00% |
Non-Preferred Brand Drugs
30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. Refer to the prescription drug list for more information. You pay a copayment for each 30 day supply. |
YES | $60.00 |
100.00% |
Nutritional Counseling
Unlimited for diabetics and mental health/substance abuse diagnosis. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $60.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Physical Therapy and Occupational Therapy - 30 visits combined per year, Speech Therapy and Speech-Language Pathology (SLP) Services - 30 visits per year, Chiropractic/Osteopathic and Manipulation Therapy - 30 visits per year. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | $30.00 |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
30 day supply at any participating pharmacy or up to a 90 day supply at a 90 day retail pharmacy. The cost-sharing payment for a covered prescription insulin drug is limited to a $50 maximum per 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. You pay a copayment for each 30 day supply. |
YES | $30.00 |
100.00% |
Prenatal and Postnatal Care
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Preventive Care/Screening/Immunization
Routine physicals and other preventive services |
YES | 0.00% |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Refer to the policy for more information about Virtual Care Services. In home visits by a Primary Care Physician are covered, refer to the policy for more information. Includes Mental Health Office Visits and Substance Use Disorder Office Visits. |
YES | $30.00 |
100.00% |
Private-Duty Nursing
Limit: 16.0 Hours per Year Included under Home Health Care Benefit |
YES | 25.00% Coinsurance after deductible |
100.00% |
Prosthetic Devices
External and internal, includes components. Coverage is also included for the repair, fitting, adjustments and replacement of a prosthetic device. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Physical Therapy and Occupational Therapy - 30 visits combined per year. Visit Limit applies separately to habilitative and rehabilitative services. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | $30.00 |
100.00% |
Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year Speech Therapy and Speech-Language Pathology (SLP) Services. Visit Limit applies separately to habilitative and rehabilitative services. These limits do not apply to the hospice benefit, early intervention benefit, and for the treatment of autism spectrum disorders. |
YES | $30.00 |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
100.00% |
Routine Foot Care
|
NO | ||
Skilled Nursing Facility
Limit: 100.0 Days per Stay |
YES | 25.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $60.00 |
100.00% |
Specialty Drugs
Including other high cost drugs. 30 day supply at any participating pharmacy or up to a 30 day supply at a 90 day retail pharmacy. Refer to the prescription drug list for more information. You pay a copayment for each 30 day supply. |
YES | $250.00 |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
Includes treatment in an outpatient department of a hospital and office visits, individual psychotherapy, group psychotherapy, psychological testing and medication management visits. Services may be received by a psychiatrist, psychologist, neuropsychologist, licensed clinical social worker (L.C.S.W.), clinical nurse specialist, licensed marriage and family therapist (L.M.F.T.), licensed professional counselor (L.P.C) or any agency licensed by the state to give these services that must be covered by law. This benefit applies to Substance Abuse Office Visits. All other Substance Abuse Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information. |
YES | $30.00 |
100.00% |
Transplant
Lifesource Travel benefit - unlimited, per insured person, per transplant |
YES | 25.00% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
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 | $45.00 |
$45.00 |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.780017779 |
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 | Limited Cost Sharing Plan Variation |
Dental Only Plan | No |
Design Type | Design 1 |
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 | VAF021 |
Formulary URL | URL |
HIOS Product ID | 41921VA002 |
Import Date | 12/14/2022 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? | No |
Issuer ID | 41921 |
Issuer Marketplace Marketing Name | Cigna Health and Life Insurance Company |
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 | VAN001 |
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) | 41921VA0020069-03 |
Plan Marketing Name | Cigna Simple Choice 2000 |
Plan Type | EPO |
Plan Variant Marketing Name | Cigna Simple Choice 2000-1 |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $2,600 |
SBC Scenario, Having a Baby, Copayment | $10 |
SBC Scenario, Having a Baby, Deductible | $2,000 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $800 |
SBC Scenario, Having Diabetes, Deductible | $900 |
SBC Scenario, Having Diabetes, Limit | $20 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $300 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $1,700 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | VAS001 |
Source Name | SERFF |
Plan ID | 41921VA0020069 |
State Code | VA |
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 | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $4000 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $2000 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $2,000 |
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 | $17400 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8700 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,700 |
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