Bronze Simple- HSA - 58081GA0010014 Health Insurance Plan

Oscar Health Plan of Georgia health insurance plan with the Plan ID 58081GA0010014. The plan is called Bronze Simple- HSA.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 64.94% (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 35.06% 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 58081GA0010014
Health Insurance Plan Year 2022
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 58081GA0010014-00
Provider Network(s) ['GAN001']
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 Georgia 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 - 58081GA0010014-00

Standard On Exchange Plan - 58081GA0010014-01

Open to Indians below 300% FPL - 58081GA0010014-02

Open to Indians above 300% FPL - 58081GA0010014-03

Last Plan Update Date Tue, 25 Jan 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.649402483
Begin Primary Care Cost-Sharing After Number Of Visits 0
Begin Primary Care Deductible Coinsurance After Number Of Copays 0
Business Year 2022
Child-Only Offering Allows Adult and Child-Only
Composite Rating Offered No
CSR Variation Type Standard Bronze Off Exchange Plan
Dental Only Plan No
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 GAF001
Formulary URL URL
HIOS Product ID 58081GA001
Import Date 1/25/2022 1:00
Limited Cost Sharing Plan Variation - Estimated Advanced Payment $0.00
Inpatient Copayment Maximum Days 0
HSA Eligible Yes
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 Expanded Bronze
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 1/1/2022
Plan Expiration Date 12/31/2022
Plan ID (Standard Component ID with Variant) 58081GA0010014-00
Plan Marketing Name Bronze Simple- HSA
Plan Type HMO
Plan Variant Marketing Name Bronze Simple- HSA
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,800
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,200
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $200
SBC Scenario, Having Diabetes, Deductible $5,200
SBC Scenario, Having Diabetes, Limit $20
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 GAS001
Source Name HIOS
Plan ID 58081GA0010014
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 50%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,200
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 $10400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $5200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $5,200
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 $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $7,000
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $14000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $7000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $7,000
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 Simple- HSA Health Insurance Plan, 58081GA0010014

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

Frequently Asked Questions(FAQ) about Bronze Simple- HSA, 58081GA0010014 Health Insurance Plan, 58081GA0010014

  • Does Bronze Simple- HSA Health Insurance Plan, 58081GA0010014 support Mail Ordering?

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

  • Does (58081GA0010014) Health Insurance Plan, Variant (58081GA0010014-00) 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 (58081GA0010014) Health Insurance Plan, Variant (58081GA0010014-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services only

    Does (58081GA0010014) Health Insurance Plan, Variant (58081GA0010014-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (58081GA0010014) Health Insurance Plan, Variant (58081GA0010014-00) 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 Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Asthma?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for Asthma.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Heart disease?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for Heart disease.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Depression?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for Depression.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Diabetes?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for Diabetes.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Low back pain?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for Low back pain.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Pregnancy?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 offers Disease Management Program for Pregnancy.

    Does Bronze Simple- HSA Health Insurance Plan, Variant (58081GA0010014-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Bronze Simple- HSA Health Insurance Plan Variant 58081GA0010014-00 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