Cigna HealthCare of Illinois, Inc. health insurance plan with the Plan ID 53882IL0040042. The plan is called Cigna Simple Choice 9100.
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 | 53882IL0040042 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 53882IL0040042-02 | ||||||||||||||||||
Provider Network(s) | ['ILN001'] | ||||||||||||||||||
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 - 53882IL0040042-00 Standard On Exchange Plan - 53882IL0040042-01 |
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Last Plan Update Date | Thu, 23 Feb 2023 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
|
YES | $0.00, 0.00% |
100.00% |
Accidental Dental
Limited to treatment for accidental injury to natural teeth within six months of the accidental injury. |
YES | $0.00, 0.00% |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $0.00, 0.00% |
100.00% |
Bariatric Surgery
Benefit depends on type of service provided |
YES | $0.00, 0.00% |
100.00% |
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
|
NO | ||
Chemotherapy
|
YES | $0.00, 0.00% |
100.00% |
Chiropractic Care
Limit: 25.0 Visit(s) per Year Includes an additional 15 visits per year for Naprapathic Services. |
YES | $0.00, 0.00% |
100.00% |
Cosmetic Surgery
Cosmetic surgery for the correction of congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
YES | $0.00, 0.00% |
100.00% |
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
Limit: 1.0 Item(s) per Year Children up to age 19, through the end of their birth month. Limit 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. One pair of contact lenses - in lieu of lenses and frames benefit, (may not receive contact lenses and frames in same benefit year). |
YES | $0.00, 0.00% |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Up to a 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. 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 unlimited Physical, Speech and Occupational Therapies. |
YES | $0.00, 0.00% |
100.00% |
Hearing Aids
Limit: 1.0 Item(s) per 2 Years Hearing aids for adults and children, 1 per ear every 24 months. Includes bone anchored hearing aids (BAHAs) with no maximum. |
YES | $0.00, 0.00% |
100.00% |
Home Health Care Services
|
YES | $0.00, 0.00% |
100.00% |
Hospice Services
Includes Respite care. |
YES | $0.00, 0.00% |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | $0.00, 0.00% |
100.00% |
Infertility Treatment
Benefit depends on type of service provided |
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
Some laboratory tests for Diabetes are covered at no charge. 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 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. |
YES | $0.00, 0.00% |
100.00% |
Nutritional Counseling
|
YES | $0.00, 0.00% |
100.00% |
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
Cardiac rehab limited to a maximum of 36 Outpatient treatment sessions within a 6 month period. Physical, Occupational and Speech Therapies are Unlimited. |
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 30 day supply at any designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
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
Physical, Occupational and Speech Therapy- Unlimited. Includes medically necessary preventive physical therapy for members diagnosed with multiple sclerosis. |
YES | $0.00, 0.00% |
100.00% |
Rehabilitative Speech Therapy
Unlimited Speech Therapy. |
YES | $0.00, 0.00% |
100.00% |
Routine Dental Services (Adult)
|
NO | ||
Routine Eye Exam (Adult)
|
NO | ||
Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year Children up to age 19, through the end of their birth month. |
YES | $0.00, 0.00% |
100.00% |
Routine Foot Care
Services associated with foot care for diabetes and peripheral vascular disease are covered when Medically Necessary as part of another Covered Service. |
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 30-day supply at any designated pharmacy or up to a 90-day supply at any 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% |
Transplant
LifeSource Facility Travel Maximum: $10,000 per insured person, per transplant and a maximum reimbursement of $50 for lodging per person, per day. |
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 | Design 1 |
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 | ILF017 |
Formulary URL | URL |
HIOS Product ID | 53882IL004 |
Import Date | 2/23/2023 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 ID | 53882 |
Issuer Marketplace Marketing Name | Cigna Healthcare |
Market Coverage | Individual |
Medical Drug Deductibles Integrated | Yes |
Medical Drug Maximum Out of Pocket Integrated | Yes |
Metal Level | Bronze |
Multiple In Network Tiers | No |
National Network | No |
Network ID | ILN001 |
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) | 53882IL0040042-02 |
Plan Marketing Name | Cigna Simple Choice 9100 |
Plan Type | HMO |
Plan Variant Marketing Name | Cigna Simple Choice-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 | $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 | ILS001 |
Source Name | SERFF |
Specialist Requiring a Referral | All Specialist |
Plan ID | 53882IL0040042 |
State Code | IL |
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 | 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