Connect Silver CMS Standard - 94419IN0010012 Health Insurance Plan

Cigna Health and Life Insurance Company health insurance plan with the Plan ID 94419IN0010012. The plan is called Connect Silver CMS Standard.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 94419IN0010012
Health Insurance Plan Year 2025
State Indiana
Health Insurance Issuer Cigna Health and Life Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 94419IN0010012-00
Provider Network(s) PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Indiana All US States
All 9094 9901
PCP 769 798
Allergy 2 2
OB/GYN 33 38
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 94419IN0010012-00

Standard On Exchange Plan - 94419IN0010012-01

Open to Indians below 300% FPL - 94419IN0010012-02

Open to Indians above 300% FPL - 94419IN0010012-03

73% AV Silver Plan - 94419IN0010012-04

87% AV Silver Plan - 94419IN0010012-05

94% AV Silver Plan - 94419IN0010012-06

Last Plan Update Date Thu, 15 Aug 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Connect Silver CMS Standard Health Insurance Plan, 94419IN0010012-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Limited to treatment for accidental injury to natural teeth within 12 months of the accidental injury. Anesthesia and hospital charges for dental care, for a member less than 19 years of age or a member who is physically or mentally disabled, are covered if the member requires dental treatment to be given in a hospital or outpatient ambulatory surgical facility. The indications for General Anesthesia, as published in the reference manual of the American Academy of Pediatric Dentistry, should be used to determine whether performing dental procedures is necessary to treat the member's condition under general anesthesia. This coverage does not apply to treatment for TMJ.

YES

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Year

Includes Osteopathic/Manipulation Therapy.

YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Including nutritional therapy.

YES

40.00% Coinsurance after deductible

100.00%
Dialysis

Benefit depends on place of treatment.

YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Maximum of 1 wig per Insured Person, per year.

YES

40.00% 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

40.00% Coinsurance after deductible

40.00% 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

40.00% Coinsurance after deductible

40.00% Coinsurance 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. 1 pair of glasses (lenses and frames from pediatric selection) per 12 month period. Contact lenses for Children - One pair or one box per eye of contact lenses, including professional services - in lieu of lenses and frame benefit, (may not receive contact lenses and frames in same benefit year).

YES

No Charge

100.00%
Gender Affirming Care
NO
Generic Drugs

You pay a copayment for each 30 day supply. Up to a 30-day supply at a Participating Pharmacy, or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.

YES

$20.00

100.00%
Habilitation Services

Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for Rehabilitation Services.

YES

$40.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 100.0 Visit(s) per Year

Maximum does not include home infusion therapy or private duty nursing rendered in the home.

YES

40.00% Coinsurance after deductible

100.00%
Hospice Services

Short-term Inpatient Hospital care when needed in periods of crisis or as respite care. Skilled nursing services, home health aide services, and homemaker/custodial care services given by or under the supervision of a registered nurse. Social services and counseling services from a licensed social worker. Nutritional support such as intravenous feeding and feeding tubes. Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist. Pharmaceuticals, medical equipment, and supplies needed for pain management and the palliative care of your condition, including oxygen and related respiratory therapy supplies. Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the Member's death. Bereavement services are available to surviving Members for one year after the Member's death..

YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

40.00% 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

40.00% 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

$40.00

100.00%
Non-Preferred Brand Drugs

You pay a copayment for each 30 day supply ,after deductible. Up to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.

YES

$80.00 Copay after deductible

100.00%
Nutritional Counseling

.

YES

40.00% Coinsurance after deductible

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

$80.00

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

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Physical therapy limited to 20 visits per year; Occupational therapy limited to 20 visits per year; Speech therapy limited to 20 visits per year. Maximums for Habilitative Services do not reduce maximums for Rehabilitation Services. Cardiac Rehabilitation limited to 36 visits per year. Pulmonary Rehabilitation limited to 20 visits per year.

YES

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

You pay a copayment for each 30 day supply. Up to a 30-day supply at a Participating Pharmacy or up to a 90-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.

YES

$40.00

100.00%
Prenatal and Postnatal Care
YES

40.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
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

$40.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Year

YES

40.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limited to 20 visits per year for Occupational therapy and 20 visits per year for Physical therapy; same visits and coverage apply to habilitative services.

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Same limits and coverage apply for habilitative services.

YES

$40.00

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, through the end of their birth month.

YES

No Charge

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs

Including other high cost drugs. You pay a copayment for each 30 day supply, after deductible. Up to a 30-day supply at a Participating Pharmacy or up to a 30-day supply at a Designated 90-day Retail Pharmacy. Refer to the prescription drug list for more information.

YES

$350.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% 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

$40.00

100.00%
Transplant

Lifesource Travel maximum of $10,000 per transplant. Includes coverage for unrelated donor search services up to $30,000 per transplant; prior authorization required. 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

40.00% 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

40.00% Coinsurance after deductible

100.00%

Connect Silver CMS Standard Health Insurance Plan Variant 94419IN0010012-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7001186159724491
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 Standard Silver Off Exchange Plan
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 INF006
Formulary URL URL
HIOS Product ID 94419IN001
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 ID 94419
Issuer Marketplace Marketing Name Cigna Healthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID INN001
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) 94419IN0010012-00
Plan Marketing Name Connect Silver CMS Standard
Plan Type EPO
Plan Variant Marketing Name Connect Silver CMS Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $0
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 $900
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 $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID INS001
Source Name HIOS
Plan ID 94419IN0010012
State Code IN
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
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 $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
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 No
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Connect Silver CMS Standard Health Insurance Plan, 94419IN0010012

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

Frequently Asked Questions(FAQ) about Connect Silver CMS Standard, 94419IN0010012 Health Insurance Plan, 94419IN0010012

  • Does Connect Silver CMS Standard Health Insurance Plan, 94419IN0010012 support Mail Ordering?

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

  • Does (94419IN0010012) Health Insurance Plan, Variant (94419IN0010012-00) offer Disease Management Programs?

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

    Does (94419IN0010012) Health Insurance Plan, Variant (94419IN0010012-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (94419IN0010012) Health Insurance Plan, Variant (94419IN0010012-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Only

    Does (94419IN0010012) Health Insurance Plan, Variant (94419IN0010012-00) 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 Silver CMS Standard Health Insurance Plan, Variant (94419IN0010012-00) offer Disease Management Programs for Asthma?

    Yes, the Connect Silver CMS Standard Health Insurance Plan Variant 94419IN0010012-00 offers Disease Management Program for Asthma.

    Does Connect Silver CMS Standard Health Insurance Plan, Variant (94419IN0010012-00) offer Disease Management Programs for Heart disease?

    Yes, the Connect Silver CMS Standard Health Insurance Plan Variant 94419IN0010012-00 offers Disease Management Program for Heart disease.

    Does Connect Silver CMS Standard Health Insurance Plan, Variant (94419IN0010012-00) offer Disease Management Programs for Diabetes?

    Yes, the Connect Silver CMS Standard Health Insurance Plan Variant 94419IN0010012-00 offers Disease Management Program for Diabetes.

    Does Connect Silver CMS Standard Health Insurance Plan, Variant (94419IN0010012-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Connect Silver CMS Standard Health Insurance Plan Variant 94419IN0010012-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Connect Silver CMS Standard Health Insurance Plan, Variant (94419IN0010012-00) offer Disease Management Programs for Pregnancy?

    Yes, the Connect Silver CMS Standard Health Insurance Plan Variant 94419IN0010012-00 offers Disease Management Program for Pregnancy.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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