Connect Bronze 5500 Indiv Med Deductible - 73943NC0070028 Health Insurance Plan
Cigna HealthCare of North Carolina, Inc. health insurance plan with the Plan ID 73943NC0070028. The plan is called Connect Bronze 5500 Indiv Med Deductible.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 63.91% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 36.09% 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 65.71% (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 34.29% 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 | 73943NC0070028 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Cigna HealthCare of North Carolina, Inc. | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 73943NC0070028-03 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 24 Dec 2024 06:21 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 73943NC0070028-00 Standard On Exchange Plan - 73943NC0070028-01 |
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| Last Plan Update Date | Thu, 15 Aug 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 24 Dec 2024 06:21 GMT |
Benefits of Connect Bronze 5500 Indiv Med Deductible Health Insurance Plan, 73943NC0070028-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
30 visit limit for Physical Therapy and Occupational Therapy combined (including chiropractic). |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Dialysis
Benefit depends on place of treatment. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| 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 | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year Children up to age 19. Limited to 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. |
YES | No Charge |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
You pay a copayment for each 30 day supply. 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 Designated 90-day Pharmacy. Refer to the prescription drug list for more information. |
YES | $3.00 |
100.00% |
| Habilitation Services
Combined 30 visit limit for occupational and physical therapies. Speech Therapy limited to 30 visits per year. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years Limited to one hearing aid, per hearing impaired ear, every 36 months. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Includes services related to the diagnosis, treatment and correction of conditions resulting in infertility. Excludes treatment of infertility such as in vitro fertilization and other types of artificial or surgical means of conception and associated procedures and the related medications are Not Covered. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
This benefit applies to Mental Health Office Visits. All other Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information. |
YES | $100.00 |
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 Pharmacy. Refer to the prescription drug list for more information. |
YES | 49.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limited to preventive services only, as part of the Preventive Care benefit. |
YES | No Charge |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $100.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Cardiac Rehabilitation limited to 30 visits per year; Pulmonary Rehabilitation limited to 1 course per year. Physical Therapy, Occupational Therapy, Chiropractic Care limited to 30 combined visits per year; Speech Therapy limited to 30 visits per year. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
You pay a copayment for each 30 day supply, after deductible. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information. |
YES | $150.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
Routine physicals and other preventive services. |
YES | No Charge |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Refer to the policy for more information about Virtual Care Services. |
YES | $15.00 |
100.00% |
| Private-Duty Nursing
Medically necessary care while receiving active care management, prior authorization required. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year Children up to age 19. Limited to 1 visit per 12 month period. |
YES | No Charge |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Includes Mental Health Office Visits and Substance Use Disorder Office Visits. |
YES | $100.00 |
100.00% |
| Specialty Drugs
Including other high cost drugs. Up to a 30-day supply at any Participating Pharmacy or up to a 90-day supply at a Designated 90-day Pharmacy. Refer to the prescription drug list for more information. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
This benefit applies to Substance Abuse Disorder Office Visits. All other Outpatient Services are covered at the Outpatient professional services benefit. Please refer to the SBC for more information. |
YES | $100.00 |
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 any Designated 90 day retail pharmacy. Refer to the prescription drug list for more information. |
YES | $25.00 |
100.00% |
| Transplant
See policy for additional information on Cigna LifeSOURCE Designated Transplant Network Facility. |
YES | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% 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 | $60.00 |
$60.00 |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Connect Bronze-1 5500 Indiv Med Deductible Health Insurance Plan Variant 73943NC0070028-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.657090200593072 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| 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 | 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 | NCF002 |
| Formulary URL | URL |
| HIOS Product ID | 73943NC007 |
| Import Date | 2024-08-15 01:01:23 |
| 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 | 63.91% |
| Issuer ID | 73943 |
| Issuer Marketplace Marketing Name | Cigna Healthcare |
| Market Coverage | Individual |
| Medical Drug Deductibles Integrated | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Expanded Bronze |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | NCN001 |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 73943NC0070028-03 |
| Plan Marketing Name | Connect Bronze 5500 Indiv Med Deductible |
| Plan Type | HMO |
| Plan Variant Marketing Name | Connect Bronze-1 5500 Indiv Med Deductible |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $3,500 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $5,500 |
| 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 | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 73943NC0070028 |
| State Code | NC |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,500 |
| 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 | $18400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,200 |
| 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 5500 Indiv Med Deductible Health Insurance Plan, 73943NC0070028
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Connect Bronze 5500 Indiv Med Deductible, 73943NC0070028 Health Insurance Plan, 73943NC0070028
-
Does Connect Bronze 5500 Indiv Med Deductible Health Insurance Plan, 73943NC0070028 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (73943NC0070028) Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs?
Does (73943NC0070028) Health Insurance Plan, Variant (73943NC0070028-03) have Out Of Country Coverage?
Does (73943NC0070028) Health Insurance Plan, Variant (73943NC0070028-03) have Out of Service Area Coverage?
Does (73943NC0070028) Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs?
Does Connect Bronze-1 5500 Indiv Med Deductible Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs for Asthma?
Does Connect Bronze-1 5500 Indiv Med Deductible Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs for Heart disease?
Does Connect Bronze-1 5500 Indiv Med Deductible Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs for Diabetes?
Does Connect Bronze-1 5500 Indiv Med Deductible Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Connect Bronze-1 5500 Indiv Med Deductible Health Insurance Plan, Variant (73943NC0070028-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 24 Dec 2024 06:21 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