Gold Elite Saver Plus - 58081GA0010035 Health Insurance Plan
Oscar Health Plan of Georgia health insurance plan with the Plan ID 58081GA0010035. The plan is called Gold Elite Saver Plus.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.27% (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 20.73% 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 | 58081GA0010035 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Georgia | ||||||||||||||||||
| Health Insurance Issuer | Oscar Health Plan of Georgia | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 58081GA0010035-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 23 Apr 2024 07:07 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 58081GA0010035-00 Standard On Exchange Plan - 58081GA0010035-01 |
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| Last Plan Update Date | Wed, 27 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 23 Apr 2024 07:07 GMT |
Benefits of Gold Elite Saver Plus Health Insurance Plan, 58081GA0010035-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $200.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $25.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $200.00 |
100.00% |
| Chiropractic Care
Coverage available for Spinal Manipulation under Rehabilitative Physical Therapy benefit. |
YES | $25.00 |
100.00% |
| Cosmetic Surgery
|
YES | $1,000.00 |
100.00% |
| Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of 3 days. |
YES | $1,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 20.00% |
100.00% |
| Durable Medical Equipment
|
YES | 20.00% |
100.00% |
| Emergency Room Services
|
YES | $500.00 |
$500.00 |
| Emergency Transportation/Ambulance
|
YES | $500.00 |
$500.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | $1,000.00 |
100.00% |
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $10.00 |
100.00% |
| Habilitation Services
Limit: 40.0 Visit(s) per Year 40 visits combined per Benefit Period for Habilitation Services. |
YES | $25.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 120.0 Visit(s) per Year |
YES | $25.00 |
100.00% |
| Hospice Services
|
YES | 20.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $375.00 |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
YES | 20.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $200.00 |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $0.00 Tier 2: $25.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $25.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $250.00 Copay after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | $10.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Only covers orthodontic treatment for a congenital anomaly related to or developed as a result of cleft palate, with or without cleft lip. Medically Necessary Orthodontia only. |
YES | 20.00% |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $10.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $500.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year 40 visits combined per Benefit Period for Outpatient Rehabilitation Services. |
YES | $25.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $200.00 |
100.00% |
| Preferred Brand Drugs
|
YES | $75.00 Copay after deductible |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
The recommendations by the USPSTF for breast cancer screenings, mammography and preventions issued prior to November 2009 will be considered current. Immunizations covered are those recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and virtual services. |
YES | $10.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 20.00% |
100.00% |
| Radiation
|
YES | 20.00% |
100.00% |
| Reconstructive Surgery
|
YES | $1,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year |
YES | $25.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | $25.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| 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: 60.0 Days per Year The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Specialist Visit
Cost share applies to both in-person and virtual services. |
YES | $25.00 |
100.00% |
| Specialty Drugs
|
YES | $350.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $25.00 |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant. |
YES | $1,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 20.00% |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $50.00 |
100.00% |
| Weight Loss Programs
Limit: 4.0 Visit(s) per Year Medically necessary nutritional counseling for the treatment of obesity, which includes morbid obesity. |
YES | $10.00 |
100.00% |
| Well Baby Visits and Care
Care provided for birth through age 5. |
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $75.00 |
100.00% |
Gold Elite Saver Plus Health Insurance Plan Variant 58081GA0010035-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.792654388648318 |
| 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 | Standard Gold Off Exchange Plan |
| 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 | 20.00% |
| Drug EHB Deductible, In Network (Tier 1), Family Per Group | $400 per group |
| Drug EHB Deductible, In Network (Tier 1), Family Per Person | $200 per person |
| Drug EHB Deductible, In Network (Tier 1), Individual | $200 |
| Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 20.00% |
| Drug EHB Deductible, In Network (Tier 2), Family Per Group | $400 per group |
| Drug EHB Deductible, In Network (Tier 2), Family Per Person | $200 per person |
| Drug EHB Deductible, In Network (Tier 2), Individual | $200 |
| 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, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 20% |
| Formulary ID | GAF001 |
| Formulary URL | URL |
| HIOS Product ID | 58081GA001 |
| Import Date | 2023-09-27 20:02:01 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 58081 |
| Issuer Marketplace Marketing Name | Oscar Health Plan of Georgia |
| 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 | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 1), Individual | $0 |
| Medical EHB Deductible, In Network (Tier 2), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Medical EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Medical EHB Deductible, In Network (Tier 2), Individual | $0 |
| 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 | Gold |
| Multiple In Network Tiers | Yes |
| National Network | No |
| Network ID | GAN001 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 58081GA0010035-00 |
| Plan Marketing Name | Gold Elite Saver Plus |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold Elite Saver Plus |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,800 |
| SBC Scenario, Having Diabetes, Deductible | $200 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | GAS001 |
| Source Name | SERFF |
| Plan ID | 58081GA0010035 |
| State Code | GA |
| 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 | $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), In Network (Tier 2), Family Per Group | $16000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), 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 Gold Elite Saver Plus Health Insurance Plan, 58081GA0010035
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold Elite Saver Plus, 58081GA0010035 Health Insurance Plan, 58081GA0010035
-
Does Gold Elite Saver Plus Health Insurance Plan, 58081GA0010035 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58081GA0010035) Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs?
Does (58081GA0010035) Health Insurance Plan, Variant (58081GA0010035-00) have Out Of Country Coverage?
Does (58081GA0010035) Health Insurance Plan, Variant (58081GA0010035-00) have Out of Service Area Coverage?
Does (58081GA0010035) Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs for Asthma?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs for Heart disease?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs for Depression?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs for Diabetes?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (58081GA0010035-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 23 Apr 2024 07:07 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