Silver Classic Standard - 69512MO0010052 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 69512MO0010052. The plan is called Silver Classic 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 69512MO0010052
Health Insurance Plan Year 2025
State Missouri
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 69512MO0010052-00
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 Missouri All US States
All 11067 78048
PCP 977 2161
Allergy 5 8
OB/GYN 47 101
Dentists 14 18
Available Variants of the Health Plan

Standard Off Exchange Plan - 69512MO0010052-00

Standard On Exchange Plan - 69512MO0010052-01

Open to Indians below 300% FPL - 69512MO0010052-02

Open to Indians above 300% FPL - 69512MO0010052-03

73% AV Silver Plan - 69512MO0010052-04

87% AV Silver Plan - 69512MO0010052-05

94% AV Silver Plan - 69512MO0010052-06

Last Plan Update Date Thu, 17 Oct 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of Silver Classic Standard Health Insurance Plan, 69512MO0010052-00

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

Benefits include only services for a "therapeutic abortion," which is an abortion performed to save the life of the mother. Public funding is not prohibited when an abortion is performed to save the life of the mother.

NO
Accidental Dental

Limit: 3000.0 Dollars per Episode

Treatment must begin within 12 months of the injury

YES

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$80.00

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

Chiropractic visits beyond 26 per benefit period require Prior Authorization

YES

$80.00

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
YES

$0.00

100.00%
Dialysis

Covered Services include dialysis treatments in an outpatient dialysis, or home dialysis and training for you and the person who will help you with home self- dialysis

YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Exclusions: Non-Medically Necessary enhancements to standard equipment and devices.

YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

Covered lenses and frames each available at limit of one per year

YES

50.00%

100.00%
Gender Affirming Care
NO
Generic Drugs
YES

$20.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Benefit Period

Exclusions: ABA for autism only covered through age 18.

Habilitative services definition: "help you keep, learn or improve skills and functioning for daily living."

YES

$40.00

100.00%
Hearing Aids

Exclusions: Not covered for adults aged 19 and older

Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening. Limited to 1 hearing aid per ear, every 4 years, for children through age 18.

YES

40.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 100.0 Visit(s) per Benefit Period

To be eligible for benefits, you must essentially be confined to the home, as an alternative to a Hospital stay, and be physically unable to get needed medical services on an outpatient basis

YES

$80.00

100.00%
Hospice Services
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Infertility Treatment

Exclusions: Fertility treatments such as artificial insemination and in-vitro fertilization are not a Covered Service.

Covered Services include diagnostic tests to find the cause of infertility and services to treat the underlying medical conditions that cause infertility

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

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

$40.00

100.00%
Non-Preferred Brand Drugs
YES

$80.00 Copay after deductible

100.00%
Nutritional Counseling
YES

$40.00

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

$40.00

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

40.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Benefit Period

To be Covered Services, rehabilitation services must involve goals you can reach in a reasonable period of time. Benefits will end when treatment is no longer Medically Necessary and you stop progressing toward those goals.

YES

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$40.00

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

$40.00

100.00%
Private-Duty Nursing

Limit: 82.0 Visit(s) per Benefit Period

Exclusions: Private Duty Nursing Services excluded if given in a Hospital or Skilled Nursing Facility.

Private duty nursing services are a Covered Service only when given as part of the "Home Care Services" benefit. Private Duty Lifetime Maximum: 164 visits In- and Out-of-Network combined.

YES

$80.00

100.00%
Prosthetic Devices

Benefits include the purchase, fitting, adjustments, repairs and replacements

YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include reconstructive surgery to correct significant deformities caused by congenital or developmental abnormalities, illness, injury or an earlier treatment in order to create a more normal appearance.

YES

40.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Benefit Period

20 visit limit each for PT and OT.

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Unlimited visits for speech therapy.

YES

$40.00

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

Exclusions: Coverage is only available if Medically Necessary

Coverage is available if Medically Necessary.

YES

$80.00

100.00%
Skilled Nursing Facility

Limit: 150.0 Days per Benefit Period

Limit is for in-and out-of-network combined and includes rehab and outpatient day rehab.

YES

40.00% Coinsurance after deductible

100.00%
Specialist Visit

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

YES

$80.00

100.00%
Specialty Drugs
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

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

$40.00

100.00%
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Exclusions: Covered Services do not include fixed or removable appliances that involve movement or repositioning of the teeth, repair of teeth (fillings), or prosthetics (crowns, bridges, dentures)

Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services.

YES

40.00% 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

$60.00

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

0.00%

100.00%
X-rays and Diagnostic Imaging
YES

40.00% Coinsurance after deductible

100.00%

Silver Classic Standard Health Insurance Plan Variant 69512MO0010052-00 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, Depression, Diabetes, Pregnancy
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID MOF004
Formulary URL URL
HIOS Product ID 69512MO001
Import Date 2024-10-17 01:02:25
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 69512
Issuer Marketplace Marketing Name Oscar Insurance Company
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 MON001
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) 69512MO0010052-00
Plan Marketing Name Silver Classic Standard
Plan Type EPO
Plan Variant Marketing Name Silver Classic Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,500
SBC Scenario, Having a Baby, Copayment $20
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,400
SBC Scenario, Having Diabetes, Deductible $100
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,200
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID MOS001
Source Name HIOS
Plan ID 69512MO0010052
State Code MO
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 Silver Classic Standard Health Insurance Plan, 69512MO0010052

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

Frequently Asked Questions(FAQ) about Silver Classic Standard, 69512MO0010052 Health Insurance Plan, 69512MO0010052

  • Does Silver Classic Standard Health Insurance Plan, 69512MO0010052 support Mail Ordering?

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

  • Does (69512MO0010052) Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs?

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

    Does (69512MO0010052) Health Insurance Plan, Variant (69512MO0010052-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (69512MO0010052) Health Insurance Plan, Variant (69512MO0010052-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services Only

    Does (69512MO0010052) Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs?

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

    Does Silver Classic Standard Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs for Asthma?

    Yes, the Silver Classic Standard Health Insurance Plan Variant 69512MO0010052-00 offers Disease Management Program for Asthma.

    Does Silver Classic Standard Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs for Heart disease?

    Yes, the Silver Classic Standard Health Insurance Plan Variant 69512MO0010052-00 offers Disease Management Program for Heart disease.

    Does Silver Classic Standard Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs for Depression?

    Yes, the Silver Classic Standard Health Insurance Plan Variant 69512MO0010052-00 offers Disease Management Program for Depression.

    Does Silver Classic Standard Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs for Diabetes?

    Yes, the Silver Classic Standard Health Insurance Plan Variant 69512MO0010052-00 offers Disease Management Program for Diabetes.

    Does Silver Classic Standard Health Insurance Plan, Variant (69512MO0010052-00) offer Disease Management Programs for Pregnancy?

    Yes, the Silver Classic Standard Health Insurance Plan Variant 69512MO0010052-00 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