Gold Elite Saver Plus | with Atrium Health - 69803NC0010066 Health Insurance Plan

Oscar Health Plan of North Carolina, Inc health insurance plan with the Plan ID 69803NC0010066. The plan is called Gold Elite Saver Plus | with Atrium Health.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.84% (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 20.16% 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 69803NC0010066
Health Insurance Plan Year 2025
State North Carolina
Health Insurance Issuer Oscar Health Plan of North Carolina, Inc
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 69803NC0010066-00
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 North Carolina All US States
All 19414 79856
PCP 2273 2906
Allergy 3 6
OB/GYN 105 125
Dentists 4 6
Available Variants of the Health Plan

Standard Off Exchange Plan - 69803NC0010066-00

Standard On Exchange Plan - 69803NC0010066-01

Open to Indians below 300% FPL - 69803NC0010066-02

Open to Indians above 300% FPL - 69803NC0010066-03

Last Plan Update Date Fri, 11 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, 69803NC0010066-00

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

Exclusions: Excludes injury related to chewing or biting.

YES

$200.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$25.00

100.00%
Bariatric Surgery
YES

$1,000.00

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

$200.00

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

30 visit limits for PT and OT combined (including chiropractic).

YES

$25.00

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

The per day copayment will apply for a maximum of three (3) days. See plan documents for separate professional services cost shares.

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

Exclusions: Appliances and accessories that serve no medical purpose or that are primarily for comfort or convenience; repair or replacement of equipment due to abuse or desire for new equipment

Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.

YES

20.00%

100.00%
Emergency Room Services
YES

$500.00

$500.00
Emergency Transportation/Ambulance

Exclusions: Excludes services provided primarily for the convenience of travel, transportation to or from a doctor's office or dialysis center, transportation for the purpose of receiving services that are not considered Covered Services

YES

$500.00

$500.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

50.00%

100.00%
Gender Affirming Care
NO
Generic Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document

YES

Tier 1: $3.00

Tier 2: $10.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Cognitive Therapy. Group classes for pulmonary rehabilitation.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

$25.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months.

YES

20.00%

100.00%
Home Health Care Services

Exclusions: Excludes homemaker services, such as cooking and housekeeping; Dietitian services or meals; Services that are provided by a close relative or a member of the household.

YES

$25.00

100.00%
Hospice Services

Exclusions: Excludes homemaker services, such as cooking, housekeeping, and food or meal preparation.

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

YES

20.00%

100.00%
Imaging (CT/PET Scans, MRIs)

Exclusions: Lab tests that are not ordered by Doctor of Other Provider.

YES

$375.00

100.00%
Infertility Treatment

Limit: 3.0 Treatment(s) per Lifetime

YES

20.00%

100.00%
Infusion Therapy
YES

20.00%

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

Exclusions: Admissions primarily for the purpose of receiving diagnostic services or a physical examination; admissions primarily for the purpose of receiving therapy services, except when the admission is a continuation of treatment following care at an inpatient facility for an illness or accident requiring therap

The per day copayment will apply for a maximum of three (3) days.

YES

$1,000.00 Copay per Day

100.00%
Inpatient Physician and Surgical Services
YES

$200.00

100.00%
Laboratory Outpatient and Professional Services

Exclusions: Lab tests that are not ordered by a Doctor or Other Provider.

YES

$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

Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient

The per day copayment will apply for a maximum of three (3) days.

YES

$1,000.00 Copay per Day

100.00%
Mental/Behavioral Health Outpatient Services

Exclusions: Excludes counseling with relatives about a patient

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

$0.00

100.00%
Non-Preferred Brand Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document

YES

$220.00

100.00%
Nutritional Counseling

Nutritional counseling visits are separate from the obesity-related office visits

YES

$0.00

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

$0.00

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

$500.00

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Exclusions: Applied Behavior Analysis (ABA) therapy; Cognitive therapy; Speech therapy for stammering or stuttering; Group classes for pulmonary rehabilitation; music therapy, remedial reading, recreational or activity therapy, all forms or special education and supplies or equipment used similarly; maintenance therapy; massage therapy.

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

$25.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$200.00

100.00%
Preferred Brand Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document

YES

$75.00

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

$0.00

100.00%
Private-Duty Nursing

Exclusions: Excludes services provided by a close relative or a member of the household

YES

$25.00

100.00%
Prosthetic Devices

Exclusions: Dental appliances except when medically necessary for the treatment of temporomandibular joint disease or obstructive sleep apnea; cosmetic improvements, such as implants of hair follicles and skin tone enhancements; lenses for keratoconus or any other eye procedure except as specifically covered under the health plan.

Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.

YES

20.00%

100.00%
Radiation
YES

20.00%

100.00%
Reconstructive Surgery

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

YES

$1,000.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services

YES

$25.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

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 Benefit Period

YES

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

The per day copayment will apply for a maximum of three (3) days.

YES

$1,000.00 Copay per Day

100.00%
Specialist Visit

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

YES

$25.00

100.00%
Specialty Drugs

Exclusions: Excludes injections by a health care professional of injectable which can be self-administered, unless medical supervision is required; drugs associated with conception by artificial means; experimental drugs as outlined in document

YES

$550.00

100.00%
Substance Abuse Disorder Inpatient Services

Exclusions: Excludes, "Inpatient confinements that are primarily intended as a change of environment"; Counseling with relatives of a patient

The per day copayment will apply for a maximum of three (3) days.

YES

$1,000.00 Copay per Day

100.00%
Substance Abuse Disorder Outpatient Services

Exclusions: Excludes counseling with relatives about a patient

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

$0.00

100.00%
Transplant

Exclusions: The purchase price of organs or tissue if any organ or tissue is sold rather than donated to the recipient member; the procurement of organs, tissue, bone marrow, or peripheral blood stem cells or any other donor services if a recipient is not a member; transplants, including high dose chemotherapy, considered experimental or investigational; services for or related to the transplantation of animal or artificial organ or tissues.

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage

YES

$1,000.00

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: Excludes Treatment for periodontal disease; Dental implants or root canals; Crowns and bridges; Orthodontic brace; Occlusal (bite) adjustments; Extractions.

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.

YES

20.00%

100.00%
Urgent Care Centers or Facilities

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

YES

$50.00

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

0.00%

100.00%
X-rays and Diagnostic Imaging

Exclusions: Lab tests that are not ordered by a Doctor or Other Provider.

YES

$75.00

100.00%

Gold Elite Saver Plus | with Atrium Health Health Insurance Plan Variant 69803NC0010066-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7984383628455609
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 Off Exchange Plan
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 44%
Formulary ID NCF001
Formulary URL URL
HIOS Product ID 69803NC001
Import Date 2024-10-11 01:02:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 3
HSA Eligible No
New/Existing Plan New
Notice Required for Pregnancy No
Is a Referral Required for Specialist? No
Issuer ID 69803
Issuer Marketplace Marketing Name Oscar Health Plan of North Carolina, Inc
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers Yes
National Network No
Network ID NCN001
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) 69803NC0010066-00
Plan Marketing Name Gold Elite Saver Plus | with Atrium Health
Plan Type HMO
Plan Variant Marketing Name Gold Elite Saver Plus | with Atrium Health
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 $1,700
SBC Scenario, Having Diabetes, Deductible $0
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 56%
Service Area ID NCS002
Source Name HIOS
Plan ID 69803NC0010066
State Code NC
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 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 20.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $0
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,700
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 | with Atrium Health Health Insurance Plan, 69803NC0010066

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

Frequently Asked Questions(FAQ) about Gold Elite Saver Plus | with Atrium Health, 69803NC0010066 Health Insurance Plan, 69803NC0010066

  • Does Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, 69803NC0010066 support Mail Ordering?

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

  • Does (69803NC0010066) Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs?

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

    Does (69803NC0010066) Health Insurance Plan, Variant (69803NC0010066-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (69803NC0010066) Health Insurance Plan, Variant (69803NC0010066-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services Only

    Does (69803NC0010066) Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs?

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

    Does Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs for Asthma?

    Yes, the Gold Elite Saver Plus | with Atrium Health Health Insurance Plan Variant 69803NC0010066-00 offers Disease Management Program for Asthma.

    Does Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold Elite Saver Plus | with Atrium Health Health Insurance Plan Variant 69803NC0010066-00 offers Disease Management Program for Heart disease.

    Does Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs for Depression?

    Yes, the Gold Elite Saver Plus | with Atrium Health Health Insurance Plan Variant 69803NC0010066-00 offers Disease Management Program for Depression.

    Does Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold Elite Saver Plus | with Atrium Health Health Insurance Plan Variant 69803NC0010066-00 offers Disease Management Program for Diabetes.

    Does Gold Elite Saver Plus | with Atrium Health Health Insurance Plan, Variant (69803NC0010066-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold Elite Saver Plus | with Atrium Health Health Insurance Plan Variant 69803NC0010066-00 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