Gold Classic Standard (Choice) - 11574IL0010053 Health Insurance Plan

Oscar Health Plan, Inc. health insurance plan with the Plan ID 11574IL0010053. The plan is called Gold Classic Standard (Choice).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 11574IL0010053
Health Insurance Plan Year 2025
State Illinois
Health Insurance Issuer Oscar Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 11574IL0010053-01
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 Illinois All US States
All 21612 110824
PCP 2511 8220
Allergy 5 13
OB/GYN 121 221
Dentists 24 26
Available Variants of the Health Plan

Standard Off Exchange Plan - 11574IL0010053-00

Standard On Exchange Plan - 11574IL0010053-01

Open to Indians below 300% FPL - 11574IL0010053-02

Open to Indians above 300% FPL - 11574IL0010053-03

Last Plan Update Date Wed, 16 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Gold Classic Standard (Choice) Health Insurance Plan, 11574IL0010053-01

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
YES

$0.00

100.00%
Accidental Dental
YES

25.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$60.00

100.00%
Bariatric Surgery
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 25.0 Visit(s) per Benefit Period

YES

$60.00

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

25.00% Coinsurance after deductible

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Services must be rendered by a physician, or duly certified, or licensed health care professional with expertise in diabetes management.

YES

$0.00

100.00%
Dialysis
YES

25.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

25.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

25.00% Coinsurance after deductible

25.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

50.00%

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$15.00

100.00%
Habilitation Services

Treatment must be medically necessary and therapeutic and not investigational.

YES

$30.00

100.00%
Hearing Aids

Limit: 2.0 Visit(s) per 3 Years

Benefits are for bone anchored hearing aids. Quantity limit applies to hearing aids for children.

YES

25.00% Coinsurance after deductible

100.00%
Home Health Care Services

Benefits will be provided for services under a Coordinated Home Care Program.

YES

$60.00

100.00%
Hospice Services
YES

25.00% Coinsurance after deductible

100.00%
Imaging (CT/PET Scans, MRIs)

Benefit provided for outpatient services and when these services are related to surgery or medical.

YES

25.00% Coinsurance after deductible

100.00%
Infertility Treatment

Limitations vary based on procedures.

YES

25.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

25.00% Coinsurance after deductible

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

25.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

25.00% 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

25.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

$30.00

100.00%
Non-Preferred Brand Drugs
YES

$60.00

100.00%
Nutritional Counseling
YES

$30.00

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

$30.00

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

25.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services
YES

$30.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

25.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$30.00

100.00%
Prenatal and Postnatal Care
YES

0.00%

100.00%
Preventive Care/Screening/Immunization
YES

0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Cost share applies to both in-person and telemedicine services.

YES

$30.00

100.00%
Private-Duty Nursing
YES

$60.00

100.00%
Prosthetic Devices
YES

25.00% Coinsurance after deductible

100.00%
Radiation
YES

25.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Only includes benefits for mastectomy-related services.

YES

25.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Maintenance Speech Therapy is not covered.

YES

$30.00

100.00%
Rehabilitative Speech Therapy

When rendered for the treatment of psychosocial speech delay, behavioral problems (including impulsive behavior and impulsivity syndrome) attention disorder, conceptual handicap or mental retardation, except as may be provided under this Certificate for Autism Spectrum Disorder(s).

YES

$30.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Benefit Period

YES

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility
YES

25.00% Coinsurance after deductible

100.00%
Specialist Visit

Cost share applies to both in-person and telemedicine services.

YES

$60.00

100.00%
Specialty Drugs
YES

$250.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

25.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services

The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information.

YES

$30.00

100.00%
Transplant
YES

25.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

25.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.

YES

$45.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

0.00%

100.00%
X-rays and Diagnostic Imaging

Benefit provided for outpatient services and when these services are related to surgery or medical care.

YES

25.00% Coinsurance after deductible

100.00%

Gold Classic Standard (Choice) Health Insurance Plan Variant 11574IL0010053-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7806125763529309
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 Gold On Exchange Plan
Dental Only Plan No
Design Type Design 1
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9975
First Tier Utilization 100%
Formulary ID ILF003
Formulary URL URL
HIOS Product ID 11574IL001
Import Date 2024-10-16 20:01:50
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? Yes
Issuer ID 11574
Issuer Marketplace Marketing Name Oscar Health Plan, 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 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 and Urgent Services Only
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan Expiration Date 2025-12-31
Plan ID (Standard Component ID with Variant) 11574IL0010053-01
Plan Marketing Name Gold Classic Standard (Choice)
Plan Type HMO
Plan Variant Marketing Name Gold Classic Standard (Choice)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,400
SBC Scenario, Having a Baby, Copayment $20
SBC Scenario, Having a Baby, Deductible $1,500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,100
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $200
SBC Scenario, Treatment of a Simple Fracture, Copayment $200
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID ILS001
Source Name SERFF
Specialist Requiring a Referral All Specialist Providers
Plan ID 11574IL0010053
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 25.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $3000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $1500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $1,500
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 $15600 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7800 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,800
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 Gold Classic Standard (Choice) Health Insurance Plan, 11574IL0010053

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

Frequently Asked Questions(FAQ) about Gold Classic Standard (Choice), 11574IL0010053 Health Insurance Plan, 11574IL0010053

  • Does Gold Classic Standard (Choice) Health Insurance Plan, 11574IL0010053 support Mail Ordering?

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

  • Does (11574IL0010053) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does (11574IL0010053) Health Insurance Plan, Variant (11574IL0010053-01) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (11574IL0010053) Health Insurance Plan, Variant (11574IL0010053-01) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services Only

    Does (11574IL0010053) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does Gold Classic Standard (Choice) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs for Asthma?

    Yes, the Gold Classic Standard (Choice) Health Insurance Plan Variant 11574IL0010053-01 offers Disease Management Program for Asthma.

    Does Gold Classic Standard (Choice) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs for Heart disease?

    Yes, the Gold Classic Standard (Choice) Health Insurance Plan Variant 11574IL0010053-01 offers Disease Management Program for Heart disease.

    Does Gold Classic Standard (Choice) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs for Depression?

    Yes, the Gold Classic Standard (Choice) Health Insurance Plan Variant 11574IL0010053-01 offers Disease Management Program for Depression.

    Does Gold Classic Standard (Choice) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs for Diabetes?

    Yes, the Gold Classic Standard (Choice) Health Insurance Plan Variant 11574IL0010053-01 offers Disease Management Program for Diabetes.

    Does Gold Classic Standard (Choice) Health Insurance Plan, Variant (11574IL0010053-01) offer Disease Management Programs for Pregnancy?

    Yes, the Gold Classic Standard (Choice) Health Insurance Plan Variant 11574IL0010053-01 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