Bronze Classic - 69512MO0010003 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 69512MO0010003. The plan is called Bronze Classic.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 61.59% (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 38.41% 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 | 69512MO0010003 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Missouri | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69512MO0010003-00 | ||||||||||||||||||
| Provider Network(s) | ['MON001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 69512MO0010003-00 Standard On Exchange Plan - 69512MO0010003-01 |
||||||||||||||||||
| Last Plan Update Date | Tue, 28 Feb 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of Bronze Classic Health Insurance Plan, 69512MO0010003-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
Limit: 3000.0 Dollars per Episode Treatment must begin within 12 months of the injury. |
YES | $350.00 Copay after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $350.00 Copay after deductible |
100.00% |
| Chiropractic Care
Chiropractic visits beyond 26 per benefit period require Prior Authorization. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
|
YES | 50.00% 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 | $350.00 Copay after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 50.00% Coinsurance after deductible |
50.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 50.00% Coinsurance after deductible |
50.00% 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
|
YES | 50.00% 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: $30.00 |
100.00% |
| Habilitation Services
Limit: 20.0 Visit(s) per Benefit Period Habilitative services definition: 'help you keep, learn or improve skills and functioning for daily living.' |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
Benefits include hearing aids provided to a newborn for initial amplification following a newborn hearing screening. |
YES | 50.00% 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 | 50.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $10.00 Copay after deductible Tier 2: $50.00 Copay 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 | 50.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $1200.00 Copay 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 | 50.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $350.00 Copay after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $250.00 Copay after deductible |
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
One (1) non-preventive visit is $50 and not subject to the deductible. 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 | $50.00, 50.00% Coinsurance after deductible |
100.00% |
| Private-Duty Nursing
Limit: 82.0 Visit(s) per Benefit Period 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 | 50.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
Benefits include the purchase, fitting, adjustments, repairs and replacements. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% 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 | 50.00% 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 | 50.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
Unlimited visits for speech therapy. |
YES | 50.00% 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
Coverage is available if Medically Necessary. |
YES | $0.00 |
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 | 50.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Transplant
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Covered Services include removable appliances for TMJ repositioning and related surgery, medical care, and diagnostic services. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 50.00% Coinsurance after deductible |
100.00% |
Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 69512MO0010003-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.615918741 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 1 |
| Business Year | 2023 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Bronze Off Exchange 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 | 1 |
| First Tier Utilization | 20% |
| Formulary ID | MOF001 |
| Formulary URL | URL |
| HIOS Product ID | 69512MO001 |
| Import Date | 2/28/2023 1:02 |
| 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 | Expanded Bronze |
| Multiple In Network Tiers | Yes |
| 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 | 1/1/2023 |
| Plan Expiration Date | 12/31/2023 |
| Plan ID (Standard Component ID with Variant) | 69512MO0010003-00 |
| Plan Marketing Name | Bronze Classic |
| Plan Type | EPO |
| Plan Variant Marketing Name | Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $1,400 |
| SBC Scenario, Having a Baby, Copayment | $0 |
| SBC Scenario, Having a Baby, Deductible | $7,750 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $80 |
| SBC Scenario, Having Diabetes, Deductible | $5,100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | MOS001 |
| Source Name | HIOS |
| Plan ID | 69512MO0010003 |
| 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 | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $15500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $7750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $7,750 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 50.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $15500 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $7750 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $7,750 |
| 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 | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $9,100 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $18200 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $9100 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $9,100 |
| 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 Bronze Classic Health Insurance Plan, 69512MO0010003
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Bronze Classic, 69512MO0010003 Health Insurance Plan, 69512MO0010003
-
Does Bronze Classic Health Insurance Plan, 69512MO0010003 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69512MO0010003) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs?
Does (69512MO0010003) Health Insurance Plan, Variant (69512MO0010003-00) have Out Of Country Coverage?
Does (69512MO0010003) Health Insurance Plan, Variant (69512MO0010003-00) have Out of Service Area Coverage?
Does (69512MO0010003) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Asthma?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Heart disease?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Depression?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Diabetes?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Low back pain?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Pregnancy?
Does Bronze Classic ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (69512MO0010003-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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