Cigna Connect HSA 7050 - 53882IL0040031 Health Insurance Plan
Cigna HealthCare of Illinois, Inc. health insurance plan with the Plan ID 53882IL0040031. The plan is called Cigna Connect HSA 7050.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 64.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 35.95% 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 64.05% (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 35.95% 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 | 53882IL0040031 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 53882IL0040031-01 | ||||||||||||||||||
| Provider Network(s) | ['ILN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 53882IL0040031-00 Standard On Exchange Plan - 53882IL0040031-01 |
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| Last Plan Update Date | Thu, 23 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Cigna Connect HSA 7050 Health Insurance Plan, 53882IL0040031-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
YES | No Charge after deductible |
100.00% |
| Accidental Dental
Limited to treatment for accidental injury to natural teeth within six months of the accidental injury. |
YES | No Charge after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | No Charge after deductible |
100.00% |
| Bariatric Surgery
Benefit depends on type of service provided |
YES | No Charge after deductible |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | No Charge after deductible |
100.00% |
| Chiropractic Care
Limit: 25.0 Visit(s) per Year Includes an additional 15 visits per year for Naprapathic Services. |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
|
YES | No Charge after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | No Charge after deductible |
100.00% |
| Dialysis
Benefit depends on place of treatment |
YES | No Charge after deductible |
100.00% |
| Durable Medical Equipment
|
YES | No Charge 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 | No Charge after deductible |
No Charge 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 | No Charge after deductible |
No Charge after deductible |
| 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 | 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 designated pharmacy, or up to a 90 day supply at any designated 90 day retail pharmacy. Formulary Diabetic Supplies are covered at no charge, after deductible. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Habilitation Services
Includes unlimited Physical, Speech and Occupational Therapies. |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Home Health Care Services
|
YES | No Charge after deductible |
100.00% |
| Hospice Services
Includes Respite care. |
YES | No Charge after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | No Charge after deductible |
100.00% |
| Infertility Treatment
Benefit depends on type of service provided |
YES | No Charge after deductible |
100.00% |
| Infusion Therapy
|
YES | No Charge after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | No Charge after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | No Charge after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
Some laboratory tests for Diabetes are covered at no charge after deductible. Refer to the policy for more information regarding Diabetes. |
YES | No Charge 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 | No Charge after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Nutritional Counseling
|
YES | No Charge after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | No Charge after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | No Charge after deductible |
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, after deductible. Refer to the prescription drug list for more information. |
YES | No Charge after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge after deductible |
100.00% |
| Preventive Care/Screening/Immunization
|
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 | No Charge after deductible |
100.00% |
| Private-Duty Nursing
|
YES | No Charge after deductible |
100.00% |
| Prosthetic Devices
|
YES | No Charge after deductible |
100.00% |
| Radiation
|
YES | No Charge after deductible |
100.00% |
| Reconstructive Surgery
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Rehabilitative Speech Therapy
Unlimited Speech Therapy. |
YES | No Charge after deductible |
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 | No Charge |
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 | No Charge after deductible |
100.00% |
| Skilled Nursing Facility
|
YES | No Charge after deductible |
100.00% |
| Specialist Visit
|
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | No Charge after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | No Charge after deductible |
100.00% |
| Tier 2 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. |
YES | No Charge after deductible |
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 | No Charge after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | No Charge 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 | No Charge after deductible |
No Charge after deductible |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | No Charge after deductible |
100.00% |
Cigna Connect HSA 7050 Health Insurance Plan Variant 53882IL0040031-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.640546015 |
| 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 | Standard Bronze On Exchange Plan |
| 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 | 0.998 |
| First Tier Utilization | 100% |
| Formulary ID | ILF002 |
| 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 | Yes |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 64.05% |
| 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 | Expanded 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) | 53882IL0040031-01 |
| Plan Marketing Name | Cigna Connect HSA 7050 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Cigna Connect HSA 7050 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,050 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $300 |
| SBC Scenario, Having Diabetes, Deductible | $2,300 |
| SBC Scenario, Having Diabetes, Limit | $20 |
| 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 | $2,400 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | ILS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All Specialist |
| Plan ID | 53882IL0040031 |
| State Code | IL |
| 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 | 0.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $14100 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7050 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,050 |
| 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 | $14100 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7050 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,050 |
| 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 Cigna Connect HSA 7050 Health Insurance Plan, 53882IL0040031
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Cigna Connect HSA 7050, 53882IL0040031 Health Insurance Plan, 53882IL0040031
-
Does Cigna Connect HSA 7050 Health Insurance Plan, 53882IL0040031 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (53882IL0040031) Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs?
Does (53882IL0040031) Health Insurance Plan, Variant (53882IL0040031-01) have Out Of Country Coverage?
Does (53882IL0040031) Health Insurance Plan, Variant (53882IL0040031-01) have Out of Service Area Coverage?
Does (53882IL0040031) Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs?
Does Cigna Connect HSA 7050 Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs for Asthma?
Does Cigna Connect HSA 7050 Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs for Heart disease?
Does Cigna Connect HSA 7050 Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs for Diabetes?
Does Cigna Connect HSA 7050 Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Cigna Connect HSA 7050 Health Insurance Plan, Variant (53882IL0040031-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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