Bronze Simple- HSA - 23552TN0020014 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 23552TN0020014. The plan is called Bronze Simple- HSA.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 100.00% (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 0.00% 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 23552TN0020014
Health Insurance Plan Year 2023
State Tennessee
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 23552TN0020014-02
Provider Network(s) ['TNN001']
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 Tennessee 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 - 23552TN0020014-00

Standard On Exchange Plan - 23552TN0020014-01

Open to Indians below 300% FPL - 23552TN0020014-02

Open to Indians above 300% FPL - 23552TN0020014-03

Last Plan Update Date Wed, 01 Mar 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Bronze Simple- HSA Health Insurance Plan, 23552TN0020014-02

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

$0.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00

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

$0.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

YES

$0.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$0.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

$0.00

100.00%
Durable Medical Equipment

Durable medical equipment over $500 requires prior authorization.

YES

$0.00

100.00%
Emergency Room Services
YES

$0.00

$0.00
Emergency Transportation/Ambulance
YES

$0.00

$0.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Benefit Period

YES

$0.00

100.00%
Gender Affirming Care
YES

$0.00

100.00%
Generic Drugs

Deductible waived for Oscar?s HSA preventive drug list.

YES

Tier 1: $0.00

Tier 2: $0.00

100.00%
Habilitation Services

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

YES

$0.00

100.00%
Hearing Aids

Limit: 1.0 Item(s) per 3 Years

YES

$0.00

100.00%
Home Health Care Services

Limit: 60.0 Visit(s) per Year

YES

$0.00

100.00%
Hospice Services

Prior Authorization required for Inpatient Hospice.

YES

$0.00

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

$0.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00

100.00%
Inpatient Physician and Surgical Services
YES

$0.00

100.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: $0.00

Tier 2: $0.00

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

$0.00

100.00%
Mental/Behavioral Health Outpatient Services
YES

$0.00

100.00%
Non-Preferred Brand Drugs
YES

$0.00

100.00%
Nutritional Counseling

For Diabetes Treatment only.

YES

$0.00

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

$0.00

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

$0.00

100.00%
Outpatient Rehabilitation Services

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. The limit on the number of visits for therapy applies to all visits for that therapy, whether received in a Practitioner's office, outpatient facility or home health setting.

YES

$0.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00

100.00%
Preferred Brand Drugs

Deductible waived for Oscar?s HSA preventive drug list.

YES

$0.00

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
YES

$0.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

$0.00

100.00%
Radiation
YES

$0.00

100.00%
Reconstructive Surgery

Covered Services: Surgery to correct significant defects from congenital causes, (except where specifically excluded), accidents or disfigurement from a disease state. Reconstructive breast Surgery as a result of a mastectomy or partial mastectomy (other than lumpectomy).

YES

$0.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.

YES

$0.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Therapy limited to 20 visits per type per year. Physical, speech or occupational therapy provided in the home does not require Prior Authorization.

YES

$0.00

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 Year

Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined.

YES

$0.00

100.00%
Specialist Visit
YES

$0.00

100.00%
Specialty Drugs
YES

$0.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00

100.00%
Transplant

Transplant services or supplies that have not received Prior Authorization will not be Covered.

YES

$0.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00

100.00%
Urgent Care Centers or Facilities
YES

$0.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

$0.00

100.00%
X-rays and Diagnostic Imaging
YES

$0.00

100.00%

$0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1
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 Zero Cost Sharing Plan Variation
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 TNF001
Formulary URL URL
HIOS Product ID 23552TN002
Import Date 3/1/2023 1:01
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? No
Issuer ID 23552
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 TNN001
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) 23552TN0020014-02
Plan Marketing Name Bronze Simple- HSA
Plan Type EPO
Plan Variant Marketing Name $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $0
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $0
SBC Scenario, Having Diabetes, Deductible $0
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 $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID TNS001
Source Name HIOS
Plan ID 23552TN0020014
State Code TN
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 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $0
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 0.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $0 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $0 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $0
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $0
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, 23552TN0020014

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

Frequently Asked Questions(FAQ) about Bronze Simple- HSA, 23552TN0020014 Health Insurance Plan, 23552TN0020014

  • Does Bronze Simple- HSA Health Insurance Plan, 23552TN0020014 support Mail Ordering?

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

  • Does (23552TN0020014) Health Insurance Plan, Variant (23552TN0020014-02) 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 (23552TN0020014) Health Insurance Plan, Variant (23552TN0020014-02) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (23552TN0020014) Health Insurance Plan, Variant (23552TN0020014-02) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (23552TN0020014) Health Insurance Plan, Variant (23552TN0020014-02) 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 $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Asthma?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for Asthma.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Heart disease?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for Heart disease.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Depression?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for Depression.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Diabetes?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for Diabetes.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for High blood pressure & high cholesterol.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Low back pain?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for Low back pain.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Pregnancy?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 offers Disease Management Program for Pregnancy.

    Does $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (23552TN0020014-02) offer Disease Management Programs for Weight loss programs?

    Yes, the $0 Cost Share ($0 Primary Care + $0 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 23552TN0020014-02 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