Silver Simple PCP Saver - 58081GA0010025 Health Insurance Plan
Oscar Health Plan of Georgia health insurance plan with the Plan ID 58081GA0010025. The plan is called Silver Simple PCP Saver.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 73.45% (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 26.55% 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 | 58081GA0010025 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 58081GA0010025-04 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 22 Oct 2024 06:47 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 58081GA0010025-00 Standard On Exchange Plan - 58081GA0010025-01 Open to Indians below 300% FPL - 58081GA0010025-02 Open to Indians above 300% FPL - 58081GA0010025-03 73% AV Silver Plan - 58081GA0010025-04 |
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| Last Plan Update Date | Wed, 27 Sep 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 22 Oct 2024 06:47 GMT |
Benefits of Silver Simple PCP Saver Health Insurance Plan, 58081GA0010025-04
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
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
Coverage available for Spinal Manipulation under Rehabilitative Physical Therapy benefit. |
YES | $80.00 |
100.00% |
| Cosmetic Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| 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
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
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 |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $20.00 |
100.00% |
| Habilitation Services
Limit: 40.0 Visit(s) per Year 40 visits combined per Benefit Period for Habilitation Services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 120.0 Visit(s) per Year |
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
|
NO | ||
| Infusion Therapy
Insulin infusion devices. |
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 | Tier 1: $10.00 Tier 2: 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
|
YES | $20.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Limit: 4.0 Visit(s) per Year |
YES | $20.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $20.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 40.0 Visit(s) per Year 40 visits combined per Benefit Period for Outpatient Rehabilitation Services. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $80.00 |
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 | $20.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Limit: 40.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
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 |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Cost share applies to both in-person and virtual services. |
YES | $80.00 |
100.00% |
| Specialty Drugs
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $20.00 |
100.00% |
| Transplant
Limit: 10000.0 Dollars per Procedure Limited to a combined maximum of $10,000 per covered organ transplant. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
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 | $20.00 |
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 | 40.00% Coinsurance after deductible |
100.00% |
Silver Simple PCP Saver CSR 250 Health Insurance Plan Variant 58081GA0010025-04 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.734470706256797 |
| 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 | 73% AV Level Silver 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 | 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 | 0 |
| 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 | Yes |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Metal Level | Silver |
| 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) | 58081GA0010025-04 |
| Plan Marketing Name | Silver Simple PCP Saver |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver Simple PCP Saver CSR 250 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,200 |
| SBC Scenario, Having a Baby, Copayment | $40 |
| SBC Scenario, Having a Baby, Deductible | $4,750 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $2,000 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $200 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,600 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | GAS001 |
| Source Name | SERFF |
| Plan ID | 58081GA0010025 |
| 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 |
| 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 | $9500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $4750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $4,750 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $9500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $4750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $4,750 |
| 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 | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,200 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $14400 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $7200 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $7,200 |
| 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 Simple PCP Saver Health Insurance Plan, 58081GA0010025
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Simple PCP Saver, 58081GA0010025 Health Insurance Plan, 58081GA0010025
-
Does Silver Simple PCP Saver Health Insurance Plan, 58081GA0010025 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (58081GA0010025) Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs?
Does (58081GA0010025) Health Insurance Plan, Variant (58081GA0010025-04) have Out Of Country Coverage?
Does (58081GA0010025) Health Insurance Plan, Variant (58081GA0010025-04) have Out of Service Area Coverage?
Does (58081GA0010025) Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs?
Does Silver Simple PCP Saver CSR 250 Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs for Asthma?
Does Silver Simple PCP Saver CSR 250 Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs for Heart disease?
Does Silver Simple PCP Saver CSR 250 Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs for Depression?
Does Silver Simple PCP Saver CSR 250 Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs for Diabetes?
Does Silver Simple PCP Saver CSR 250 Health Insurance Plan, Variant (58081GA0010025-04) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 22 Oct 2024 06:47 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