Providence Oregon Standard Silver Plan - Choice Network - 56707OR1330004 Health Insurance Plan

Providence Health Plan health insurance plan with the Plan ID 56707OR1330004. The plan is called Providence Oregon Standard Silver Plan - Choice Network.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 71.20% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 28.80% of the costs of all covered benefits (according to the Issuer).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 71.86% (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 28.14% 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 56707OR1330004
Health Insurance Plan Year 2023
State Oregon
Health Insurance Issuer Providence Health Plan
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 56707OR1330004-00
Provider Network(s) ['ORN003']
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 Oregon 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 - 56707OR1330004-00

Standard On Exchange Plan - 56707OR1330004-01

Open to Indians below 300% FPL - 56707OR1330004-02

Open to Indians above 300% FPL - 56707OR1330004-03

73% AV Silver Plan - 56707OR1330004-04

87% AV Silver Plan - 56707OR1330004-05

94% AV Silver Plan - 56707OR1330004-06

Last Plan Update Date Thu, 13 Oct 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Benefits of Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, 56707OR1330004-00

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

Limit: 12.0 Visit(s) per Year

YES

$40.00

100.00%
Allergy Testing
YES

30.00% Coinsurance after deductible

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

YES

$40.00

100.00%
Cosmetic Surgery

Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.

YES

30.00% Coinsurance after deductible

100.00%
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

No Charge

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
YES

No Charge

100.00%
Gender Affirming Care

Information about gender affirming care can be found in plan documents.

YES
Generic Drugs

Limit: 30.0 Days per Month

The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.

YES

$15.00

100.00%
Habilitation Services

Limit: 30.0 Visit(s) per Year

All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.

YES

$40.00

100.00%
Hearing Aids

Limit: 2.0 Item(s) per 3 Years

1 hearing aid per ear every 3 years.

YES

30.00% Coinsurance after deductible

100.00%
Home Health Care Services
YES

30.00% Coinsurance after deductible

100.00%
Hospice Services

Respite care provided in a nursing facility subject to a maximum of five consecutive days and to a lifetime maximum benefit of 30 days.

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

30.00% 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

30.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Outpatient Services
YES

$40.00

100.00%
Non-Preferred Brand Drugs

Limit: 30.0 Days per Month

The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.

YES

50.00%

100.00%
Nutritional Counseling
YES

No Charge

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.

YES

30.00% Coinsurance after deductible

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

Practioners assisting specialists will be charged at the specialist copay

YES

$40.00

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

30.00% Coinsurance after deductible

100.00%
Outpatient Rehabilitation Services

Limit: 30.0 Visit(s) per Year

All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.

YES

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

30.00% Coinsurance after deductible

100.00%
Preferred Brand Drugs

Limit: 30.0 Days per Month

The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.

YES

$60.00

100.00%
Prenatal and Postnatal Care
YES

30.00% Coinsurance after deductible

100.00%
Preventive Care/Screening/Immunization
YES

No Charge

100.00%
Primary Care Visit to Treat an Injury or Illness
YES

$40.00

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

Covered when medically necessary due to trauma or disease, or to correct congenital deformities and anomalies.

YES

30.00% Coinsurance after deductible

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 30.0 Visit(s) per Year

All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.

YES

$40.00

100.00%
Rehabilitative Speech Therapy

Limit: 30.0 Visit(s) per Year

All therapies combined. Additional visits for specified conditions. Visit limit does not apply to treatment of mental health conditions.

YES

$40.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children
YES

No Charge

100.00%
Routine Foot Care

Covered for patients with diabetes mellitus.

YES

30.00% Coinsurance after deductible

100.00%
Skilled Nursing Facility

Limit: 60.0 Days per Year

YES

30.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

100.00%
Specialty Drugs

Limit: 30.0 Days per Month

The cost share shown is the most common amount paid by a member for drugs in this category.? Some drugs may fall under a higher or lower cost sharing amount than is listed here. For the cost share of a specific drug, see the list of covered drugs and the Summary of Benefits. Coverage is limited to a 30-day supply retail or 90-day supply mail order per fill or refill. Insulin: $80 max out of pocket for 30 day supply prior to deductible.

YES

50.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

30.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$40.00

100.00%
Telehealth - Primary Care Visit

ExpressCare Virtual No Charge

YES

$40.00

100.00%
Telehealth - Specialist
YES

$80.00

100.00%
Transplant
YES

30.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
NO
Urgent Care Centers or Facilities
YES

$70.00

$70.00 Copay after deductible
Weight Loss Programs
NO
Well Baby Visits and Care
YES

No Charge

100.00%
X-rays and Diagnostic Imaging
YES

30.00% Coinsurance after deductible

100.00%

Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.718614394
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 Silver Off Exchange Plan
Drug EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Drug EHB Deductible, In Network (Tier 1), Default Coinsurance 0.00%
Drug EHB Deductible, In Network (Tier 1), Family Per Group $0 per group
Drug EHB Deductible, In Network (Tier 1), Family Per Person $0 per person
Drug EHB Deductible, In Network (Tier 1), Individual $0
Drug EHB Deductible, Out of Network, Family Per Group per group not applicable
Drug EHB Deductible, Out of Network, Family Per Person per person not applicable
Drug EHB Deductible, Out of Network, Individual Not Applicable
Dental Only Plan No
Design Type Design 3
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 0.9983
First Tier Utilization 100%
Formulary ID ORF007
Formulary URL URL
HIOS Product ID 56707OR133
Import Date 10/13/2022 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? Yes
Issuer Actuarial Value 71.20%
Issuer ID 56707
Issuer Marketplace Marketing Name Providence Health Plan
Market Coverage Individual
Medical Drug Deductibles Integrated No
Medical Drug Maximum Out of Pocket Integrated Yes
Medical EHB Deductible, Combined In/Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Combined In/Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Combined In/Out of Network, Individual Not Applicable
Medical EHB Deductible, In Network (Tier 1), Default Coinsurance 30.00%
Medical EHB Deductible, In Network (Tier 1), Family Per Group $9600 per group
Medical EHB Deductible, In Network (Tier 1), Family Per Person $4800 per person
Medical EHB Deductible, In Network (Tier 1), Individual $4,800
Medical EHB Deductible, Out of Network, Family Per Group per group not applicable
Medical EHB Deductible, Out of Network, Family Per Person per person not applicable
Medical EHB Deductible, Out of Network, Individual Not Applicable
Metal Level Silver
Multiple In Network Tiers No
National Network No
Network ID ORN003
Out of Country Coverage Yes
Out of Country Coverage Description Emergency Only
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Emergency Care and Urgent Care
Plan Brochure URL
Plan Effective Date 1/1/2023
Plan Expiration Date 12/31/2023
Plan ID (Standard Component ID with Variant) 56707OR1330004-00
Plan Marketing Name Providence Oregon Standard Silver Plan - Choice Network
Plan Type EPO
Plan Variant Marketing Name Providence Oregon Standard Silver Plan - Choice Network
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,300.00
SBC Scenario, Having a Baby, Copayment $10.00
SBC Scenario, Having a Baby, Deductible $4,800.00
SBC Scenario, Having a Baby, Limit $60.00
SBC Scenario, Having Diabetes, Coinsurance $0.00
SBC Scenario, Having Diabetes, Copayment $1,400.00
SBC Scenario, Having Diabetes, Deductible $900.00
SBC Scenario, Having Diabetes, Limit $20.00
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $100.00
SBC Scenario, Treatment of a Simple Fracture, Copayment $400.00
SBC Scenario, Treatment of a Simple Fracture, Deductible $1,700.00
SBC Scenario, Treatment of a Simple Fracture, Limit $0.00
Service Area ID ORS003
Source Name SERFF
Specialist Requiring a Referral All Non-PCP Providers
Plan ID 56707OR1330004
State Code OR
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
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), 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 Yes
URL for Enrollment Payment URL
URL for Summary of Benefits & Coverage URL
Wellness Program Offered No

Copay & Coinsurance of Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, 56707OR1330004

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

Frequently Asked Questions(FAQ) about Providence Oregon Standard Silver Plan - Choice Network, 56707OR1330004 Health Insurance Plan, 56707OR1330004

  • Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, 56707OR1330004 support Mail Ordering?

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

  • Does (56707OR1330004) Health Insurance Plan, Variant (56707OR1330004-00) 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 (56707OR1330004) Health Insurance Plan, Variant (56707OR1330004-00) have Out Of Country Coverage?

    Yes. Details: Emergency Only

    Does (56707OR1330004) Health Insurance Plan, Variant (56707OR1330004-00) have Out of Service Area Coverage?

    Yes. Details: Emergency Care and Urgent Care

    Does (56707OR1330004) Health Insurance Plan, Variant (56707OR1330004-00) 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 Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Asthma?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for Asthma.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Heart disease?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for Heart disease.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Depression?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for Depression.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Diabetes?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for Diabetes.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Low back pain?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for Low back pain.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Pregnancy?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 offers Disease Management Program for Pregnancy.

    Does Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan, Variant (56707OR1330004-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Providence Oregon Standard Silver Plan - Choice Network Health Insurance Plan Variant 56707OR1330004-00 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