CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam) - 87416WI0070012 Health Insurance Plan
Common Ground Healthcare Cooperative health insurance plan with the Plan ID 87416WI0070012. The plan is called CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.17% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.83% 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 70.17% (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 29.83% 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 | 87416WI0070012 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Wisconsin | ||||||||||||||||||
| Health Insurance Issuer | Common Ground Healthcare Cooperative | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 87416WI0070012-03 | ||||||||||||||||||
| Provider Network(s) | ['WIN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 04 Nov 2025 05:30 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 87416WI0070012-00 Standard On Exchange Plan - 87416WI0070012-01 Open to Indians below 300% FPL - 87416WI0070012-02 Open to Indians above 300% FPL - 87416WI0070012-03 73% AV Silver Plan - 87416WI0070012-04 |
||||||||||||||||||
| Last Plan Update Date | Wed, 20 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 04 Nov 2025 05:30 GMT |
Benefits of CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam) Health Insurance Plan, 87416WI0070012-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
NO | ||
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Limit: 2.0 Exam(s) per Year Two cleanings, two X-rays (one full mouth, one bite wing), fluoride with cleanings (up to age 14, limit two per year), and sealants (up to age 14 on permanent molars only) per year. |
YES | $0.00 |
100.00% |
| Chemotherapy
Intravenous chemotherapy is covered. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Rehabilitative services must be short term. Visit limits do not apply to Manipulative Therapy. |
YES | $70.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $250.00 |
$250.00 |
| Emergency Transportation/Ambulance
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process |
YES | $20.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Services must be provided fewer than seven days each week and fewer than eight hours each day for periods of 21 days or less. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $70.00 |
100.00% |
| Non-Preferred Brand Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $70.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Rehabilitative services must be short term. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process. $15 Copay for Preferred Insulin for Gold and Silver plans. |
YES | $100.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | $0.00 |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
|
YES | $70.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 20.0 Visit(s) per Year Separate limits for OT and PT. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Rehabilitative services must be short term. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Routine Dental Services (Adult)
Limit: 2.0 Exam(s) per Year Two cleanings and two x-rays (one full mouth, one bite wing) per year. |
YES | $0.00 |
100.00% |
| Routine Eye Exam (Adult)
Limit: 1.0 Exam(s) per Year |
YES | $0.00 |
100.00% |
| 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: 30.0 Days per Stay |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $115.00 |
100.00% |
| Specialty Drugs
Not Covered if the drug is not on the formulary or is not approved via the non-formulary drug coverage exception process |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $70.00 |
100.00% |
| Transplant
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | 30.00% Coinsurance after deductible |
30.00% Coinsurance after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan Variant 87416WI0070012-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.70172486257295 |
| 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 | Limited Cost Sharing Plan Variation |
| 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 | 30.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| 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, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy |
| EHB Percent of Total Premium | 0.9666999038958042 |
| First Tier Utilization | 100% |
| Formulary ID | WIF017 |
| Formulary URL | URL |
| HIOS Product ID | 87416WI007 |
| Import Date | 2023-09-20 01:01:24 |
| 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 | Yes |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.17% |
| Issuer ID | 87416 |
| Issuer Marketplace Marketing Name | Common Ground Healthcare Cooperative |
| 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 | 30.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $10000 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | WIN001 |
| 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) | 87416WI0070012-03 |
| Plan Marketing Name | CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam) |
| Plan Type | EPO |
| Plan Variant Marketing Name | CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,300 |
| SBC Scenario, Having a Baby, Copayment | $10 |
| SBC Scenario, Having a Baby, Deductible | $5,000 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,100 |
| 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 | $600 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,100 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | WIS002 |
| Source Name | HIOS |
| Plan ID | 87416WI0070012 |
| State Code | WI |
| 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 CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam) Health Insurance Plan, 87416WI0070012
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam), 87416WI0070012 Health Insurance Plan, 87416WI0070012
-
Does CGHC Silver $5000 Ded / $5000 Rx Ded - Envision Network (Dental/Vision Exam) Health Insurance Plan, 87416WI0070012 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (87416WI0070012) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs?
Does (87416WI0070012) Health Insurance Plan, Variant (87416WI0070012-03) have Out Of Country Coverage?
Does (87416WI0070012) Health Insurance Plan, Variant (87416WI0070012-03) have Out of Service Area Coverage?
Does (87416WI0070012) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for Asthma?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for Heart disease?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for Depression?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for Diabetes?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for High blood pressure & high cholesterol?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for Low back pain?
Does CGHC Silver $5000 Ded / $5000 Rx Ded LCS - Envision Network (Dental/Vision Exam) Health Insurance Plan, Variant (87416WI0070012-03) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 04 Nov 2025 05:30 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