Oscar Health Plan, Inc. health insurance plan with the Plan ID 11574IL0020015. The plan is called Silver Simple- Specialist Saver (Select).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 87.01% (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 12.99% 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 | 11574IL0020015 | ||||||||||||||||||
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Health Insurance Plan Year | 2023 | ||||||||||||||||||
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 | 11574IL0020015-05 | ||||||||||||||||||
Provider Network(s) | ['ILN002'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 14 May 2024 06:16 GMT). |
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Available Variants of the Health Plan | Standard Off Exchange Plan - 11574IL0020015-00 Standard On Exchange Plan - 11574IL0020015-01 Open to Indians below 300% FPL - 11574IL0020015-02 Open to Indians above 300% FPL - 11574IL0020015-03 73% AV Silver Plan - 11574IL0020015-04 |
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Last Plan Update Date | Wed, 22 Feb 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 14 May 2024 06:16 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | $25.00 |
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 | $25.00 |
100.00% |
Cosmetic Surgery
Cosmetic surgery for the correction of the congenital deformities or for conditions resulting from accidental injuries, scars, tumors or disease is covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
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
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Generic Drugs
Oscar is on a mission to make your prescriptions more affordable. That?s why your savings start on day 1 of your new plan. All Oscar members have access to 24/7 virtual urgent care services. Depending on your plan, if your Oscar Virtual Urgent Care provider prescribes any prescriptions on the Generics: Tier 1a or Generics: Tier 1b list during your visit, those prescriptions will be free.* Generics: Tier 1a: Drugs on this list will never cost you more than $3, no matter who prescribes them. Check to see if your prescriptions are on the $3 Prescription List at https://www.hioscar.com/prescriptions/3-dollar-list Prescriptions included in Generics: Tier 1b will always cost you less than $30, no matter who prescribes them?even if you haven?t hit your deductible. Find out which Tiers the drugs you take are on at www.hioscar.com/search *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. Virtual visits with other providers in Oscar?s network will not be free and the additional savings will not apply. |
YES | Tier 1: $3.00 Tier 2: $6.00 |
100.00% |
Habilitation Services
Treatment must be medically necessary and therapeutic and not investigational. |
YES | 25.00% Coinsurance after deductible |
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
|
YES | $25.00 |
100.00% |
Hospice Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
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 | Tier 1: $10.00 Tier 2: $30.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
|
NO | ||
Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | $25.00 |
100.00% |
Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Nutritional Counseling
|
YES | $25.00 |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
|
NO | ||
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $25.00 |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Maintenance therapies not covered. |
YES | 25.00% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% 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
Virtual visits with an Oscar Care urgent care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent Care provider under a Silver, Gold, or Platinum plan. |
YES | $25.00 |
100.00% |
Private-Duty Nursing
|
YES | $25.00 |
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 | 25.00% Coinsurance after deductible |
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 | 25.00% 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 Benefit Period |
YES | $0.00 |
100.00% |
Routine Foot Care
Only covered for persons diagnosed with diabetes. |
YES | $0.00 |
100.00% |
Skilled Nursing Facility
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $25.00 |
100.00% |
Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | $25.00 |
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
|
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% |
Plan Attribute | Value |
---|---|
AV Calculator Output Number | 0.870113274 |
Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
Business Year | 2023 |
Child-Only Offering | Allows Adult and Child-Only |
Composite Rating Offered | No |
CSR Variation Type | 87% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
EHB Percent of Total Premium | 0.998104 |
First Tier Utilization | 20% |
Formulary ID | ILF001 |
Formulary URL | URL |
HIOS Product ID | 11574IL002 |
Import Date | 2/22/2023 20:01 |
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? | 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 | Silver |
Multiple In Network Tiers | Yes |
National Network | No |
Network ID | ILN002 |
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 | 1/1/2023 |
Plan Expiration Date | 12/31/2023 |
Plan ID (Standard Component ID with Variant) | 11574IL0020015-05 |
Plan Marketing Name | Silver Simple- Specialist Saver (Select) |
Plan Type | HMO |
Plan Variant Marketing Name | Silver Simple- Specialist Saver (Select) ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $1,900 |
SBC Scenario, Having a Baby, Copayment | $100 |
SBC Scenario, Having a Baby, Deductible | $970 |
SBC Scenario, Having a Baby, Limit | $0 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $1,200 |
SBC Scenario, Having Diabetes, Deductible | $0 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $400 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $50 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $970 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Second Tier Utilization | 80% |
Service Area ID | ILS002 |
Source Name | SERFF |
Specialist Requiring a Referral | All Specialist Providers |
Plan ID | 11574IL0020015 |
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 | $1940 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $970 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $970 |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 25.00% |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $1940 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $970 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $970 |
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 | $6000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $6000 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $3000 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $3,000 |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Disclaimer: This is based on the import(Date: Tue, 14 May 2024 06:16 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