Connect Bronze 0 Indiv Med Deductible - 15105GA0020017 Health Insurance Plan
Cigna HealthCare of Georgia, Inc. health insurance plan with the Plan ID 15105GA0020017. The plan is called Connect Bronze 0 Indiv Med Deductible.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.94% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.06% 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 70.83% (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 29.17% 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 | 15105GA0020017 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | Cigna HealthCare of Georgia, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 15105GA0020017-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 15105GA0020017-00 Standard On Exchange Plan - 15105GA0020017-01 |
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| Last Plan Update Date | Wed, 16 Aug 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Benefits of Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, 15105GA0020017-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limited to: Treatment which begins within 90 days after the date of the dental injury; and the treatment is completed within 12 months after the date of the dental injury. |
YES | 50.00% |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% |
100.00% |
| Chiropractic Care
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
YES | 50.00% |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day inpatient copayment will apply for a maximum of four (4) days. |
YES | $2,350.00 |
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 | 50.00% |
100.00% |
| Durable Medical Equipment
Includes orthotics used to support, align, prevent or correct deformities. |
YES | 50.00% |
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 | $1,300.00 |
$1,300.00 |
| 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. Coverage for Medically Necessary transport to the nearest facility capable of handling the Emergency Medical Condition. |
YES | 50.00% |
50.00% |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | No Charge |
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 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 | $8.00 |
100.00% |
| Habilitation Services
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
YES | 50.00% |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 120.0 Visit(s) per Year |
YES | 50.00% |
100.00% |
| Hospice Services
Life Expectancy of 18 months or less. Excludes Respite Care. |
YES | 50.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
YES | 50.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day inpatient copayment will apply for a maximum of four (4) days. |
YES | $2,350.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% |
100.00% |
| Laboratory Outpatient and Professional Services
Refer to the policy for more information regarding Diabetes. |
YES | $70.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
The per day inpatient copayment will apply for a maximum of four (4) days. |
YES | $2,350.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information. |
YES | 50.00% |
100.00% |
| Non-Preferred Brand Drugs
Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90 day Retail Pharmacy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year Nutritional counseling for diabetics, unlimited. |
YES | 50.00% |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $125.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% |
100.00% |
| Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
YES | 50.00% |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% |
100.00% |
| Preferred Brand Drugs
Up to a 30-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 30 day supply. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information. |
YES | $250.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% |
100.00% |
| Preventive Care/Screening/Immunization
Routine physicals and other preventive services. MDLive Virtual Wellness is covered as Preventive Care. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Includes Mental Health Office Visits and Substance Use Disorder Office Visits. Refer to the policy for more information about Virtual Care Services. |
YES | $60.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% |
100.00% |
| Radiation
|
YES | 50.00% |
100.00% |
| Reconstructive Surgery
Reconstructive Surgery to restore a bodily function or to correct a deformity caused by Injury or congenital defect of a Newborn child, or for Medically Necessary Reconstructive Surgery performed to restore symmetry incident to a mastectomy or lumpectomy. |
YES | 50.00% |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
YES | 50.00% |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year Physical Therapy, Occupational Therapy, Speech Therapy, Audiology, Cognitive Rehabilitation, Spinal Manipulations/Adjustments (Chiropractic Care) Maximum does not apply to services for treatment of Autism Spectrum Disorders. Limited to a combined maximum of 40 visits per calendar year. |
YES | 50.00% |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Exam(s) per Year |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 50.00% |
100.00% |
| Specialist Visit
|
YES | $125.00 |
100.00% |
| Specialty Drugs
Including other high cost drugs. Up to a 30-day supply at any Participating Pharmacy or up to a 30-day supply at a Designated 90 day Retail Pharmacy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
The per day inpatient copayment will apply for a maximum of four (4) days. |
YES | $2,350.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
This benefit applies to all other Outpatient Services excluding Office Visits. Mental Health Office Visits are covered at the Primary care doctor visit copayment. Please refer to the SBC for more information. |
YES | 50.00% |
100.00% |
| Tier-2 Generic Drugs
You pay a copayment for each 30 day supply. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. |
YES | $40.00 |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure LifeSource Travel and Lodging Benefit Maximum: $10,000 per Insured Person per transplant. See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility. |
YES | No Charge |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% |
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 | $75.00 |
$75.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% |
100.00% |
Connect Bronze 0 Indiv Med Deductible Health Insurance Plan Variant 15105GA0020017-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.708275956460125 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange 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 | 50.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5500 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $5,500 |
| 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 |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | GAF009 |
| Formulary URL | URL |
| HIOS Product ID | 15105GA002 |
| Import Date | 2023-08-16 20:01:48 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 4 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 64.94% |
| Issuer ID | 15105 |
| Issuer Marketplace Marketing Name | Cigna HealthCare of Georgia, Inc |
| 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 | 50.00% |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | GAN001 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 15105GA0020017-00 |
| Plan Marketing Name | Connect Bronze 0 Indiv Med Deductible |
| Plan Type | HMO |
| Plan Variant Marketing Name | Connect Bronze 0 Indiv Med Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $5,300 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $400 |
| SBC Scenario, Having Diabetes, Copayment | $1,300 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $900 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $700 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | GAS001 |
| Source Name | SERFF |
| Plan ID | 15105GA0020017 |
| State Code | GA |
| 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 | $18900 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9450 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,450 |
| 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 |
Copay & Coinsurance of Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, 15105GA0020017
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Bronze 0 Indiv Med Deductible, 15105GA0020017 Health Insurance Plan, 15105GA0020017
-
Does Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, 15105GA0020017 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (15105GA0020017) Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs?
Does (15105GA0020017) Health Insurance Plan, Variant (15105GA0020017-00) have Out Of Country Coverage?
Does (15105GA0020017) Health Insurance Plan, Variant (15105GA0020017-00) have Out of Service Area Coverage?
Does (15105GA0020017) Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs?
Does Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs for Asthma?
Does Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs for Heart disease?
Does Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs for Diabetes?
Does Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Bronze 0 Indiv Med Deductible Health Insurance Plan, Variant (15105GA0020017-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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