Gold Elite - 57424NE0010036 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 57424NE0010036. The plan is called Gold Elite.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 81.20% (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 18.80% 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 57424NE0010036
Health Insurance Plan Year 2023
State Nebraska
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 57424NE0010036-00
Provider Network(s) ['NEN001']
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 Nebraska 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 - 57424NE0010036-00

Standard On Exchange Plan - 57424NE0010036-01

Open to Indians below 300% FPL - 57424NE0010036-02

Open to Indians above 300% FPL - 57424NE0010036-03

Last Plan Update Date Tue, 28 Feb 2023 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Gold Elite Health Insurance Plan, 57424NE0010036-00

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

30.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$50.00

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

30.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year.

YES

$50.00

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

30.00% Coinsurance after deductible

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

$0.00

100.00%
Dialysis
YES

30.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

30.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

30.00% Coinsurance after deductible

30.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

50.00%

100.00%
Gender Affirming Care
YES

30.00% 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: $25.00

100.00%
Habilitation Services

Limit: 45.0 Treatment(s) per Year

Nebraska supplemented this EHB category for Habilitative Services: 'Health care Services that help a person keep, learn, or improve skills and functioning for daily living. These Services may include physical and occupational therapy, speech language pathology and other Services for people with disabilities in a variety of Inpatient and/or Outpatient settings.' Quantitative limits on services apply to outpatient, only.

YES

$50.00 Copay after deductible

100.00%
Hearing Aids
YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services

Limit: 60.0 Days per Year

YES

$50.00

100.00%
Hospice Services

The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.

YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

30.00% Coinsurance after deductible

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

30.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: $10.00

Tier 2: $25.00

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

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$50.00

100.00%
Non-Preferred Brand Drugs
YES

30.00% Coinsurance after deductible

100.00%
Nutritional Counseling

Only for diabetes management as provided by the plan.

YES

$25.00

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

$25.00

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

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 45.0 Treatment(s) per Year

Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).

YES

$50.00 Copay after deductible

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs
YES

$75.00

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

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

$25.00

100.00%
Private-Duty Nursing
NO
Prosthetic Devices
YES

30.00% Coinsurance after deductible

100.00%
Radiation
YES

30.00% Coinsurance after deductible

100.00%
Reconstructive Surgery

Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 45.0 Visit(s) per Year

Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).

YES

$50.00 Copay after deductible

100.00%
Rehabilitative Speech Therapy

Limit: 45.0 Visit(s) per Year

Limits apply to rehab and hab combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year).

YES

$50.00 Copay 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

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$50.00

100.00%
Specialty Drugs
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$50.00

100.00%
Transplant
YES

30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

30.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$50.00

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

$0.00

100.00%
X-rays and Diagnostic Imaging
YES

$75.00

100.00%

Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.811995783
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 Gold 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 0.9995
First Tier Utilization 20%
Formulary ID NEF001
Formulary URL URL
HIOS Product ID 57424NE001
Import Date 2/28/2023 20:01
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 57424
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 Gold
Multiple In Network Tiers Yes
National Network No
Network ID NEN001
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) 57424NE0010036-00
Plan Marketing Name Gold Elite
Plan Type EPO
Plan Variant Marketing Name Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,800
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $500
SBC Scenario, Having a Baby, Limit $0
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $1,900
SBC Scenario, Having Diabetes, Deductible $0
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $500
SBC Scenario, Treatment of a Simple Fracture, Copayment $400
SBC Scenario, Treatment of a Simple Fracture, Deductible $500
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 80%
Service Area ID NES001
Source Name SERFF
Plan ID 57424NE0010036
State Code NE
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 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $1000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $500
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance 30.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group $1000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $500 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $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 $11000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $5500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $5,500
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $11000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $5500 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $5,500
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 Gold Elite Health Insurance Plan, 57424NE0010036

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

Frequently Asked Questions(FAQ) about Gold Elite, 57424NE0010036 Health Insurance Plan, 57424NE0010036

  • Does Gold Elite Health Insurance Plan, 57424NE0010036 support Mail Ordering?

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

  • Does (57424NE0010036) Health Insurance Plan, Variant (57424NE0010036-00) 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 (57424NE0010036) Health Insurance Plan, Variant (57424NE0010036-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (57424NE0010036) Health Insurance Plan, Variant (57424NE0010036-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (57424NE0010036) Health Insurance Plan, Variant (57424NE0010036-00) 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 Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Asthma?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for Asthma.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Heart disease?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for Heart disease.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Depression?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for Depression.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Diabetes?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for Diabetes.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Low back pain?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for Low back pain.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Pregnancy?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 offers Disease Management Program for Pregnancy.

    Does Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan, Variant (57424NE0010036-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Gold Elite ($3 Preferred Generic Drugs + $0 Virtual Urgent Care Visits with Select Providers) Health Insurance Plan Variant 57424NE0010036-00 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