Bronze Classic- Standard - 69803NC0010050 Health Insurance Plan

Oscar Health Plan of North Carolina, Inc health insurance plan with the Plan ID 69803NC0010050. The plan is called Bronze Classic- Standard.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.18% (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 35.82% 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 69803NC0010050
Health Insurance Plan Year 2023
State North Carolina
Health Insurance Issuer Oscar Health Plan of North Carolina, Inc
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 69803NC0010050-00
Provider Network(s) ['NCN001']
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Wed, 27 Mar 2024 12:10 GMT).

Providers North Carolina All US States
All N/A N/A
PCP N/A N/A
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 69803NC0010050-00

Standard On Exchange Plan - 69803NC0010050-01

Open to Indians below 300% FPL - 69803NC0010050-02

Open to Indians above 300% FPL - 69803NC0010050-03

Last Plan Update Date Thu, 23 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Bronze Classic- Standard Health Insurance Plan, 69803NC0010050-00

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental
YES

50.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$100.00

100.00%
Bariatric Surgery

For surgical treatment of morbid obesity.

YES

50.00% Coinsurance after deductible

100.00%
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

50.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 30.0 Visit(s) per Benefit Period

30 visit limits for PT and OT combined (including chiropractic).

YES

$100.00

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

Limit: 2.0 Visit(s) per Benefit Period

NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

50.00% Coinsurance after deductible

100.00%
Durable Medical Equipment

Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.

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 Benefit Period

YES

50.00%

100.00%
Gender Affirming Care
YES

50.00% Coinsurance after deductible

100.00%
Generic Drugs
YES

$25.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

$50.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

One hearing aid per hearing impaired ear, and replacement hearing aids for members under the age of 22. Once every 36 months.

YES

50.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

$100.00

100.00%
Hospice Services

Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less.

YES

50.00% Coinsurance after deductible

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

50.00% Coinsurance after deductible

100.00%
Infertility Treatment

Limit: 3.0 Treatment(s) per Lifetime

Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.

YES

50.00% Coinsurance after deductible

100.00%
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

50.00% 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

50.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

$100.00 Copay after deductible

100.00%
Nutritional Counseling

Nutritional counseling visits are separate from the obesity-related office visits.

YES

$50.00

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

$50.00

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

50.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

$50.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

50.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$50.00 Copay after deductible

100.00%
Prenatal and Postnatal Care
YES

$0.00

100.00%
Preventive Care/Screening/Immunization

All preventive care that is not state mandated is not covered OON.

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

$50.00

100.00%
Private-Duty Nursing
YES

$100.00

100.00%
Prosthetic Devices

Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery.

YES

50.00% Coinsurance after deductible

100.00%
Radiation
YES

50.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.

YES

50.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Benefit Period

Combined 30 visit limit for occupational and physical therapies and chiropractic services.

YES

$50.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Benefit Period

YES

$50.00

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
NO
Skilled Nursing Facility

Limit: 60.0 Days per Benefit Period

YES

50.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$100.00

100.00%
Specialty Drugs
YES

$500.00 Copay 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

100.00%
Transplant

Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage.

YES

50.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders

Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY.

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- Standard Health Insurance Plan Variant 69803NC0010050-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.641786747
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 Standard Bronze Off Exchange Plan
Dental Only Plan No
Design Type Design 1
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 100%
Formulary ID NCF001
Formulary URL URL
HIOS Product ID 69803NC001
Import Date 2/23/2023 1:01
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? No
Issuer ID 69803
Issuer Marketplace Marketing Name Oscar Health Plan of North Carolina, Inc
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Expanded Bronze
Multiple In Network Tiers No
National Network No
Network ID NCN001
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) 69803NC0010050-00
Plan Marketing Name Bronze Classic- Standard
Plan Type HMO
Plan Variant Marketing Name Bronze Classic- Standard
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,500
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $7,500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $500
SBC Scenario, Having Diabetes, Deductible $4,300
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 NCS001
Source Name HIOS
Plan ID 69803NC0010050
State Code NC
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 $15000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $7500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $7,500
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 $18000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $9000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $9,000
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 Bronze Classic- Standard Health Insurance Plan, 69803NC0010050

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

Frequently Asked Questions(FAQ) about Bronze Classic- Standard, 69803NC0010050 Health Insurance Plan, 69803NC0010050

  • Does Bronze Classic- Standard Health Insurance Plan, 69803NC0010050 support Mail Ordering?

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

  • Does (69803NC0010050) Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does (69803NC0010050) Health Insurance Plan, Variant (69803NC0010050-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services only

    Does (69803NC0010050) Health Insurance Plan, Variant (69803NC0010050-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (69803NC0010050) Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Asthma?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Asthma.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Heart disease?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Heart disease.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Depression?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Depression.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Diabetes?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Diabetes.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Low back pain?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Low back pain.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Pregnancy?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Pregnancy.

    Does Bronze Classic- Standard Health Insurance Plan, Variant (69803NC0010050-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Bronze Classic- Standard Health Insurance Plan Variant 69803NC0010050-00 offers Disease Management Program for Weight loss programs.

 

Disclaimer: This is based on the import(Date: Wed, 27 Mar 2024 12:10 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