LCS & NCS Plans
Limited Cost Sharing (LCS) & No Cost Sharing (NCS) Plans
Schedule of Benefits (SOBs) for 2024 LCS/NCS Plans
Bronze Plans
- CGHC Copay Bronze $0 Ded NCS – Envision Network
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS – Envision Network
- CGHC Bronze $9450 NCS – Envision Network
- CGHC Bronze $9450 LCS ($35 PCP Copay) – Envision Network
- CGHC Bronze $7500 NCS – Envision Network
- CGHC Bronze $7500 LCS – Envision Network
- CGHC Bronze $6000 NCS – Envision Network
- CGHC Bronze $6000 LCS – Envision Network
- CGHC Bronze Standard $7500 NCS – Envision Network
- CGHC Bronze Standard $7500 LCS – Envision Network
- CGHC Bronze $9450 NCS – Envision Network (Vision Exam)
- CGHC Bronze $9450 LCS ($35 PCP Copay) – Envision Network (Vision Exam)
- CGHC Bronze $6000 NCS – Envision Network (Vision Exam)
- CGHC Bronze $6000 LCS – Envision Network (Vision Exam)
- CGHC Bronze $7500 NCS – Envision Network (Vision Exam)
- CGHC Bronze $7500 LCS – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded NCS – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS – Envision Network (Vision Exam)
- CGHC Copay Bronze $0 Ded NCS – Envision Network (Dental/Vision Exam)
- CGHC Copay Bronze $0 Ded / $2250 Rx Ded LCS – Envision Network (Dental/Vision Exam)
Silver Plans
- CGHC Silver $4000 NCS – Envision Network
- CGHC Silver $4000 LCS – Envision Network
- CGHC Silver $5000 NCS – Envision Network
- CGHC Silver $5000 Ded / $5000 Rx Ded LCS – Envision Network
- CGHC Silver $3200 NCS – Envision Network
- CGHC Silver $3200 LCS – Envision Network
- CGHC Silver Standard $5900 NCS – Envision Network
- CGHC Silver Standard $5900 LCS – Envision Network
- CGHC Silver $5650 NCS – Envision Network
- CGHC Silver $5650 Ded / $6000 Rx Ded LCS – Envision Network
- CGHC Silver $4000 NCS – Envision Network (Vision Exam)
- CGHC Silver $4000 LCS – Envision Network (Vision Exam)
- CGHC Silver $5650 NCS – Envision Network (Vision Exam)
- CGHC Silver $5650 Ded / $6000 Rx Ded LCS – Envision Network (Vision Exam)
- CGHC Silver $5000 NCS – Envision Network (Vision Exam)
- CGHC Silver $5000 Ded / $5000 Rx Ded LCS – Envision Network (Vision Exam)
- CGHC Silver $3200 NCS – Envision Network (Vision Exam)
- CGHC Silver $3200 LCS – Envision Network (Vision Exam)
- CGHC Silver $5650 NCS – Envision Network (Dental/Vision Exam)
- CGHC Silver $5650 Ded / $6000 Rx Ded LCS – Envision Network (Dental/Vision Exam)
- CGHC Silver $5000 NCS – Envision Network (Dental/Vision Exam)
- CGHC Silver $5000 Ded / $5000 Rx Ded LCS – Envision Network (Dental/Vision Exam)
Gold Plans
- CGHC Copay Gold $0 Ded NCS – Envision Network
- CGHC Copay Gold $0 Ded LCS – Envision Network
- CGHC Gold $3000 NCS – Envision Network
- CGHC Gold $3000 LCS – Envision Network
- CGHC Gold $1800 NCS – Envision Network
- CGHC Gold $1800 LCS – Envision Network
- CGHC Gold $3200 NCS – Envision Network
- CGHC Gold $3200 LCS – Envision Network
- CGHC Gold Standard $1500 NCS – Envision Network
- CGHC Gold Standard $1500 LCS – Envision Network
- CGHC Gold $1800 NCS – Envision Network (Vision Exam)
- CGHC Gold $1800 LCS – Envision Network (Vision Exam)
- CGHC Gold $3000 NCS – Envision Network (Vision Exam)
- CGHC Gold $3000 LCS – Envision Network (Vision Exam)
- CGHC Gold $3200 NCS – Envision Network (Vision Exam)
- CGHC Gold $3200 LCS – Envision Network (Vision Exam)
- CGHC Copay Gold $0 Ded NCS – Envision Network (Vision Exam)
- CGHC Copay Gold $0 Ded LCS – Envision Network (Vision Exam)
All 2024 NCS and LCS plans offer variants with Adult Vision Exam and some with Preventive Dental add-on options.
Click here to learn more.
Schedule of Benefits (SOBs) for 2023 LCS/NCS Plans
All 2023 NCS and LCS plans offer variants with Adult Vision Exam and some with Preventive Dental add-on options.
Click here to learn more.
All plans offer the American Indian/Alaskan Native Plan Variations (Limited Cost Sharing and No Cost Sharing) for eligible individuals. Please click here for more information about those plan variations.
1 PCP = Primary Care Provider (includes general pediatrics, internal medicine, OB/GYN, family practice, general medicine, chiropractor and geriatrics) Urgent = Urgent Care Services Emergency = Emergency Room Care Services
2 Services that meet the definition of emergency are paid at the in-network rate even when care is delivered in a non-network ER. Because we do not have a contract with out of network ER facilities, we cannot prevent these facilities from billing our members for the balance of the charge. The copay applies to the facility charge only. All other charges related to ER visit are subject to deductible/coinsurance.
3 Preventive Care received out of network is not covered
4 Catastrophic plan applies to persons under age 30 or those with a hardship exemption from the federal Marketplace (healthcare.gov)
Our Deductibles, Explained: All plans have a January 1 to December 31 deductible. All deductibles, coinsurance, and copayments accumulate toward the out-of-pocket maximum. Deductibles and out-of-pocket maximums must be satisfied separately. All plans described on this page have embedded deductibles for family coverage. This means that if you are enrolled in 2-person or family coverage, an individual family member only has to satisfy the single person deductible before the plan begins to make payment for covered services for that family member.
To access your plan’s Summary of Benefits and Coverage (SBC), click here.
Common Ground Healthcare Cooperative does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.
This page provides summary information. Please refer to the certificate of coverage and schedule of benefits for a complete listing of benefits and terms of coverage. A list of exclusions and limitations can be found here.