UnitedHealthcare of Ohio, Inc. health insurance plan with the Plan ID 33931OH0030015. The plan is called UHC Silver Value $3,450 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx).
Based on the data of Health Plan Issuer, this plan has an actuarial value of 73.05% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 26.95% of the costs of all covered benefits (according to the Issuer).
Health Insurance Plan ID | 33931OH0030015 | ||||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Health Insurance Plan Year | 2023 | ||||||||||||||||||
State | Ohio | ||||||||||||||||||
Health Insurance Issuer | UnitedHealthcare of Ohio, Inc. | ||||||||||||||||||
Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
Health Insurance Plan Variant | 33931OH0030015-04 | ||||||||||||||||||
Provider Network(s) | ['OHN001'] | ||||||||||||||||||
In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 17 Sep 2024 06:33 GMT). |
|
||||||||||||||||||
Available Variants of the Health Plan | Standard Off Exchange Plan - 33931OH0030015-00 Standard On Exchange Plan - 33931OH0030015-01 Open to Indians below 300% FPL - 33931OH0030015-02 Open to Indians above 300% FPL - 33931OH0030015-03 73% AV Silver Plan - 33931OH0030015-04 |
||||||||||||||||||
Last Plan Update Date | Tue, 16 Aug 2022 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 17 Sep 2024 06:33 GMT |
Benefit | Covered | In Network | Out Of Network |
---|---|---|---|
Abortion for Which Public Funding is Prohibited
|
NO | ||
Accidental Dental
Limit: 3000.0 Dollars per Episode |
YES | 40% Coinsurance after deductible |
100.00% |
Acupuncture
|
NO | ||
Allergy Testing
|
YES | 40% Coinsurance after deductible |
100.00% |
Bariatric Surgery
|
NO | ||
Basic Dental Care - Adult
|
NO | ||
Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 40% Coinsurance after deductible |
100.00% |
Chemotherapy
|
YES | 40% Coinsurance after deductible |
100.00% |
Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period |
YES | 40% Coinsurance after deductible |
100.00% |
Cosmetic Surgery
|
NO | ||
Delivery and All Inpatient Services for Maternity Care
Coverage for the Inpatient postpartum stay for mother and newborn child in a hospital will be, at a minimum, 48 hours for a vaginal delivery and 96 hours for a cesarean section. Coverage will be for the length of stay recommended by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists in their Guidelines for Prenatal Care. Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | 40% Coinsurance after deductible |
100.00% |
Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | No Charge |
100.00% |
Diabetes Education
Diabetes Self-Management Training for an individual with insulin dependent diabetes, non-insulin dependent diabetes, or elevated blood glucose levels induced by pregnancy or another medical condition |
YES | 40% Coinsurance after deductible |
100.00% |
Dialysis
Benefits include supportive use of an artificial kidney machine |
YES | 40% Coinsurance after deductible |
100.00% |
Durable Medical Equipment
Covered services include durable medical equipment, medical devices and supplies, prosthetics and appliances, including cochlear implants and eyeglasses/contact lenses (for cataract surgery or injury), and medical/surgical supplies and equipment that serve only a medical purpose for the management of disease. Benefit limits: Wigs are limited to the first one following cancer treatment not to exceed one per Benefit Period; limit of four (4) surgical bras following mastectomy per benefit period; (as required by the Women's Health and Cancer Rights Act); Left Ventricular Artificial Devices (LVAD) covered only as bridge to heart transplant. |
YES | 40% Coinsurance after deductible |
100.00% |
Emergency Room Services
|
YES | 40% Coinsurance after deductible |
40% Coinsurance after deductible |
Emergency Transportation/Ambulance
Ambulance Services are transportation by a vehicle (including ground, water, fixed wing and rotary wing air transportation) designed, equipped and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals: from home, scene of accident or medical emergency to a hospital; between hospitals; between a hospital and skilled nursing facility; or from a hospital or skilled nursing facility to home; ambulance trips must be made to the closest facility that can give covered services appropriate for the member's condition |
YES | 40% Coinsurance after deductible |
40% Coinsurance after deductible |
Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 40% Coinsurance after deductible |
100.00% |
Gender Affirming Care
|
NO | ||
Generic Drugs
Lowest cost shares are available at preferred retail pharmacies and home delivery. See the Summary of Benefits and Coverage for cost shares at other retail pharmacies and for non-preferred generics. 90-day supplies are available through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $3.00 |
100.00% |
Habilitation Services
Limits may apply to some services; includes benefits for health care services and devices that help a person keep, learn or improve skills and functioning for daily living, including treatment of Autism Spectrum Disorders to children (0 - 21), which at a minimum shall include: (1) Out-Patient Physical Rehabilitation Services including (a) Speech and Language therapy and/or Occupational therapy, 20 visits per year of each service; and (b) Clinical Therapeutic Intervention, which include but are not limited to Applied Behavioral Analysis, 20 hours per week; and (2) Mental/Behavioral Health Outpatient Services to provide consultation, assessment, development and oversight of treatment plans |
YES | 40% Coinsurance after deductible |
100.00% |
Hearing Aids
|
NO | ||
Home Health Care Services
Limit: 100.0 Visit(s) per Benefit Period When therapy services are provided in the home (including physical, speech, and occupational therapy) as part of home health care services, they are not subject to separate visit limits for therapy services. The 100 visit/year limit is also not applicable to home infusion therapy or private duty nursing rendered in the home setting |
YES | 40% Coinsurance after deductible |
100.00% |
Hospice Services
To be eligible for Hospice benefits, the patient must have a life expectancy of six months or less, as confirmed by the attending Physician |
YES | 40% Coinsurance after deductible |
100.00% |
Imaging (CT/PET Scans, MRIs)
|
YES | 40% Coinsurance after deductible |
100.00% |
Infertility Treatment
Includes services to diagnose and treat medical conditions resulting in infertility. Excludes: Artificial insemination, in vitro fertilization, other types of artificial or surgical means of conception including drugs administered in connection with these procedures |
YES | 40% Coinsurance after deductible |
100.00% |
Infusion Therapy
Home IV therapy includes but is not limited to: injections (intra-muscular, subcutaneous, continuous subcutaneous), Total Parenteral Nutrition (TPN), Enteral nutrition therapy, antibiotic therapy, pain management and chemotherapy |
YES | 40% Coinsurance after deductible |
100.00% |
Inpatient Hospital Services (e.g., Hospital Stay)
There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient hospital services include charges from a hospital, skilled nursing facility or other provider for room, board, general nursing services; and ancillary (related) services |
YES | 40% Coinsurance after deductible |
100.00% |
Inpatient Physician and Surgical Services
There are specific exceptions to certain exclusions and/or additional exclusions that are detailed in plan document; inpatient medical care visits limited to one visit per day by any one physician. |
YES | 40% Coinsurance after deductible |
100.00% |
Laboratory Outpatient and Professional Services
|
YES | $40.00 |
100.00% |
Long-Term/Custodial Nursing Home Care
|
NO | ||
Major Dental Care - Adult
|
NO | ||
Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 40% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Inpatient Services
|
YES | 40% Coinsurance after deductible |
100.00% |
Mental/Behavioral Health Outpatient Services
|
YES | 40% Coinsurance after deductible |
100.00% |
Non-Preferred Brand Drugs
Non-preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 40% Coinsurance after deductible |
100.00% |
Nutritional Counseling
Covered benefit under home health services and covered as USPSTF A or B recommendation under preventive health services (includes diet counseling for adults at higher risk for chronic disease, obesity screening and counseling for all adults, and healthy diet counseling for adults with cardiovascular risk factors) |
YES | 40% Coinsurance after deductible |
100.00% |
Orthodontia - Adult
|
NO | ||
Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | 50% Coinsurance after deductible |
100.00% |
Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 40% Coinsurance after deductible |
100.00% |
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
See specific exceptions to these exclusions and/or additional exclusions that are detailed in plan document; benefits for facility charges for Outpatient Services are payable for the removal of teeth or for other dental processes only if the patient's medical condition or the dental procedure requires a Hospital setting to ensure the safety of the patient |
YES | 40% Coinsurance after deductible |
100.00% |
Outpatient Rehabilitation Services
Limit: 116.0 Visit(s) per Benefit Period Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, 20 visits per year for Physical Therapy, 36 visits per year for Cardiac, and 20 visits per year for Pulmonary. |
YES | 40% Coinsurance after deductible |
100.00% |
Outpatient Surgery Physician/Surgical Services
|
YES | 40% Coinsurance after deductible |
100.00% |
Preferred Brand Drugs
Preferred brand medications are available in 90-day supplies through preferred retail pharmacies or home delivery. Limited to 30 day supplies at all other pharmacies. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | $60 Copay after deductible |
100.00% |
Prenatal and Postnatal Care
Includes post-delivery follow-up care performed, by a physician or nurse, within 72 hours of discharge, through home health care visits or, at patient's discretion, in a medical setting. This coverage includes, but is not limited to parent education; assistance and training in breast or bottle feeding; and routine maternal or neonatal tests and screening (including collection of sample for hereditary and metabolic newborn screening) |
YES | No Charge |
100.00% |
Preventive Care/Screening/Immunization
Services with an 'A' or 'B' rating from the United States Preventive Services Task Force (USPSTF); Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration including: women's contraceptives, sterilization procedures, and counseling; breastfeeding support, supplies, and counseling (benefits for breast pumps are limited to one pump per benefit period); and gestational diabetes screening; routine screening mammograms; routine cytologic screening; child health supervision services from birth to age 9 |
YES | No Charge |
100.00% |
Primary Care Visit to Treat an Injury or Illness
Virtual urgent care visits via a Designated virtual provider unlimited $0 |
YES | No Charge |
100.00% |
Private-Duty Nursing
Limit: 90.0 Visit(s) per Benefit Period Private Duty Nursing Services are Covered Services only when provided through the Home Care Services benefit |
YES | 40% Coinsurance after deductible |
100.00% |
Prosthetic Devices
Benefits for artificial substitutes for body parts and tissues and materials inserted into tissue for functional or therapeutic purposes. Covered Services include purchase, fitting, needed adjustment, repairs, and replacements of prosthetic devices and supplies that 1) Replace all or part of a missing body part and its adjoining tissues; or 2) Replace all or part of the function of a permanently useless or malfunctioning body part. |
YES | 40% Coinsurance after deductible |
100.00% |
Radiation
|
YES | 40% 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. Benefits include surgery performed to restore symmetry after a mastectomy. |
YES | 40% Coinsurance after deductible |
100.00% |
Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 40.0 Visit(s) per Benefit Period Limited to 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy. |
YES | 40% Coinsurance after deductible |
100.00% |
Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Benefit Period |
YES | 40% 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 | No Charge |
100.00% |
Routine Foot Care
Not Covered except for preventive foot care due to conditions associated with metabolic, neurologic, or peripheral vascular disease. |
NO | ||
Skilled Nursing Facility
Limit: 90.0 Days per Benefit Period Benefits include Items and services provided as an inpatient in a skilled nursing bed of skilled nursing facility or hospital, including room and board in semi-private accommodations; rehabilitative services; and drugs, biologicals, and supplies furnished |
YES | 40% Coinsurance after deductible |
100.00% |
Specialist Visit
|
YES | $85.00 |
100.00% |
Specialty Drugs
Specialty medications are limited to a 30-day supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information. |
YES | 50% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Inpatient Services
|
YES | 40% Coinsurance after deductible |
100.00% |
Substance Abuse Disorder Outpatient Services
|
YES | 40% Coinsurance after deductible |
100.00% |
Transplant
Includes coverage for unrelated donor search services ($30,000 per transplant) and travel/lodging as approved by the plan ($10,000 per transplant). Transplant benefits apply to any medically necessary human organ and stem cell/bone marrow transplants (except cornea and kidney transplants) and transfusions including necessary acquisition procedures, harvest and storage, necessary preparatory myeloablative therapy, and initial evaluation/testing to determine eligibility as a transplant candidate. |
YES | 40% Coinsurance after deductible |
100.00% |
Treatment for Temporomandibular Joint Disorders
Benefits provided for temporomandibular (joint connecting the lower jaw to the temporal bone at the side of the head) and craniomandibular (head and neck muscle) disorders |
YES | 40% Coinsurance after deductible |
100.00% |
Urgent Care Centers or Facilities
|
YES | $80.00 |
100.00% |
Weight Loss Programs
|
NO | ||
Well Baby Visits and Care
|
YES | No Charge |
100.00% |
X-rays and Diagnostic Imaging
|
YES | 40% Coinsurance after deductible |
100.00% |
Plan Attribute | Value |
---|---|
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 | 73% AV Level Silver Plan |
Dental Only Plan | No |
Design Type | Not Applicable |
EHB Percent of Total Premium | 1 |
First Tier Utilization | 100% |
Formulary ID | OHF007 |
Formulary URL | URL |
HIOS Product ID | 33931OH003 |
Import Date | 8/16/2022 20:01 |
Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
Inpatient Copayment Maximum Days | 0 |
HSA Eligible | No |
New/Existing Plan | New |
Notice Required for Pregnancy | No |
Is a Referral Required for Specialist? | Yes |
Issuer Actuarial Value | 73.05% |
Issuer ID | 33931 |
Issuer Marketplace Marketing Name | UnitedHealthcare |
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 | OHN001 |
Out of Country Coverage | No |
Out of Service Area Coverage | Yes |
Out of Service Area Coverage Description | Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. |
Plan Brochure | URL |
Plan Effective Date | 1/1/2023 |
Plan ID (Standard Component ID with Variant) | 33931OH0030015-04 |
Plan Level Exclusions | 0 |
Plan Marketing Name | UHC Silver Value $3,450 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) |
Plan Type | HMO |
Plan Variant Marketing Name | UHC Silver-E Value $3,200 Deductible (Unlimited $0 Virtual Urgent Care + $0 Primary Care Visits, $3 T1 Preferred Rx) |
QHP/Non QHP | Both |
SBC Scenario, Having a Baby, Coinsurance | $3,100 |
SBC Scenario, Having a Baby, Copayment | $0 |
SBC Scenario, Having a Baby, Deductible | $3,200 |
SBC Scenario, Having a Baby, Limit | $60 |
SBC Scenario, Having Diabetes, Coinsurance | $0 |
SBC Scenario, Having Diabetes, Copayment | $500 |
SBC Scenario, Having Diabetes, Deductible | $3,200 |
SBC Scenario, Having Diabetes, Limit | $0 |
SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
SBC Scenario, Treatment of a Simple Fracture, Copayment | $80 |
SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,500 |
SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
Service Area ID | OHS001 |
Source Name | SERFF |
Specialist Requiring a Referral | All, except OBGYN and as state mandated |
Plan ID | 33931OH0030015 |
State Code | OH |
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 | $6400 per group |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $3200 per person |
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $3,200 |
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 | $14500 per group |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7250 per person |
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,250 |
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 | Yes |
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 |
---|
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, 17 Sep 2024 06:33 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