Connect Gold CMS Standard - 15105GA0020018 Health Insurance Plan

Cigna HealthCare of Georgia, Inc. health insurance plan with the Plan ID 15105GA0020018. The plan is called Connect Gold CMS Standard.

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 15105GA0020018
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 15105GA0020018-02
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).

Providers Georgia All US States
All 21921 24682
PCP 3576 3969
Allergy 15 16
OB/GYN 123 141
Dentists 19 20
Available Variants of the Health Plan

Standard Off Exchange Plan - 15105GA0020018-00

Standard On Exchange Plan - 15105GA0020018-01

Open to Indians below 300% FPL - 15105GA0020018-02

Open to Indians above 300% FPL - 15105GA0020018-03

Last Plan Update Date Wed, 16 Aug 2023 00:00 GMT
Last Import Date Tue, 24 Dec 2024 06:21 GMT

Benefits of Connect Gold CMS Standard Health Insurance Plan, 15105GA0020018-02

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

$0.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$0.00

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

$0.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$0.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Including nutritional therapy.

YES

$0.00

100.00%
Dialysis

Benefit depends on place of treatment.

YES

$0.00

100.00%
Durable Medical Equipment

Includes orthotics used to support, align, prevent or correct deformities.

YES

$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
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

$0.00

$0.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00

100.00%
Gender Affirming Care
NO
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. Formulary Diabetic Supplies are covered at no charge. Refer to the prescription drug list for more information.

YES

$0.00

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

$0.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 120.0 Visit(s) per Year

YES

$0.00

100.00%
Hospice Services

Life Expectancy of 18 months or less. Excludes Respite Care.

YES

$0.00

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00

100.00%
Infertility Treatment
NO
Infusion Therapy

Insulin infusion devices.

YES

$0.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00

100.00%
Inpatient Physician and Surgical Services
YES

$0.00

100.00%
Laboratory Outpatient and Professional Services

Refer to the policy for more information regarding Diabetes.

YES

$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

100.00%
Mental/Behavioral Health Outpatient Services

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

$0.00

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. You pay a copayment for each 30 day supply.

YES

$0.00

100.00%
Nutritional Counseling

Limit: 4.0 Visit(s) per Year

Nutritional counseling for diabetics, unlimited.

YES

$0.00

100.00%
Orthodontia - Adult
NO
Orthodontia - Child
NO
Other Practitioner Office Visit (Nurse, Physician Assistant)
YES

$0.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

$0.00

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

$0.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00

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

$0.00

100.00%
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization

Routine physicals and other preventive services. MDLive Virtual Wellness is covered as Preventive Care.

YES

$0.00

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

$0.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

$0.00

100.00%
Radiation
YES

$0.00

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

$0.00

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

$0.00

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

$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

YES

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

$0.00

100.00%
Specialist Visit
YES

$0.00

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. You pay a copayment for each 30 day supply.

YES

$0.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00

100.00%
Substance Abuse Disorder Outpatient Services

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

$0.00

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

$0.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$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
Weight Loss Programs
NO
Well Baby Visits and Care

Care provided for birth through age 5.

YES

$0.00

100.00%
X-rays and Diagnostic Imaging
YES

$0.00

100.00%

Connect CMS Standard-0 Health Insurance Plan Variant 15105GA0020018-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 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 1.0
First Tier Utilization 100%
Formulary ID GAF010
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 0
HSA Eligible No
New/Existing Plan Existing
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 15105
Issuer Marketplace Marketing Name Cigna HealthCare of Georgia, Inc
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 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) 15105GA0020018-02
Plan Marketing Name Connect Gold CMS Standard
Plan Type HMO
Plan Variant Marketing Name Connect CMS Standard-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 GAS001
Source Name SERFF
Plan ID 15105GA0020018
State Code GA
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 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 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 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 $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

Copay & Coinsurance of Connect Gold CMS Standard Health Insurance Plan, 15105GA0020018

Drug Tier Pharmacy Type Copay amount Copay option Coinsurance rate Coinsurance option Mail Order

Frequently Asked Questions(FAQ) about Connect Gold CMS Standard, 15105GA0020018 Health Insurance Plan, 15105GA0020018

  • Does Connect Gold CMS Standard Health Insurance Plan, 15105GA0020018 support Mail Ordering?

    Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.

  • Does (15105GA0020018) Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does (15105GA0020018) Health Insurance Plan, Variant (15105GA0020018-02) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (15105GA0020018) Health Insurance Plan, Variant (15105GA0020018-02) have Out of Service Area Coverage?

    Yes. Details: Emergency Services Only

    Does (15105GA0020018) Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Diabetes, High Blood Pressure & High Cholesterol, Pregnancy

    Does Connect CMS Standard-0 Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs for Asthma?

    Yes, the Connect CMS Standard-0 Health Insurance Plan Variant 15105GA0020018-02 offers Disease Management Program for Asthma.

    Does Connect CMS Standard-0 Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs for Heart disease?

    Yes, the Connect CMS Standard-0 Health Insurance Plan Variant 15105GA0020018-02 offers Disease Management Program for Heart disease.

    Does Connect CMS Standard-0 Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs for Diabetes?

    Yes, the Connect CMS Standard-0 Health Insurance Plan Variant 15105GA0020018-02 offers Disease Management Program for Diabetes.

    Does Connect CMS Standard-0 Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Connect CMS Standard-0 Health Insurance Plan Variant 15105GA0020018-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Connect CMS Standard-0 Health Insurance Plan, Variant (15105GA0020018-02) offer Disease Management Programs for Pregnancy?

    Yes, the Connect CMS Standard-0 Health Insurance Plan Variant 15105GA0020018-02 offers Disease Management Program 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