Silver Classic- Standard - 20069TX0100052 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 20069TX0100052. The plan is called Silver Classic- Standard.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 70.44% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 29.56% 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 70.06% (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 29.94% 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 | 20069TX0100052 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2023 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 20069TX0100052-00 | ||||||||||||||||||
| Provider Network(s) | ['TXN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 16 Apr 2024 06:19 GMT). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 20069TX0100052-00 Standard On Exchange Plan - 20069TX0100052-01 Open to Indians below 300% FPL - 20069TX0100052-02 Open to Indians above 300% FPL - 20069TX0100052-03 73% AV Silver Plan - 20069TX0100052-04 |
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| Last Plan Update Date | Wed, 01 Mar 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 16 Apr 2024 06:19 GMT |
Benefits of Silver Classic- Standard Health Insurance Plan, 20069TX0100052-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $80.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $80.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Will cover 48-hour hospital stay for uncomplicated vaginal delivery and 96-hour hospital stay for uncomplicated caesarean section. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 40.00% Coinsurance after deductible |
40.00% Coinsurance after deductible |
| Eye Glasses for Children
|
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | 40.00% 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. $0 unlimited visits with your Oscar Virtual Primary Care team. This plan gives you access to the Oscar Virtual Primary Care through your Oscar mobile app or online account. Visits with this team are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, if your Oscar Virtual Primary Care team prescribes you any prescriptions on the Generics: Tier 1a and Generics: Tier 1b list, those prescriptions will be free.* *For these savings to apply, drugs must be prescribed by your Oscar Care virtual 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. Please refer to your plan documents for more information. |
YES | $20.00 |
100.00% |
| Habilitation Services
Limit: 35.0 Visit(s) per Year Habilitative and rehabilitative limits cannot be combined for plans issued or renewed on or after January 1, 2017. Habilitation services includes autism services, and the benchmark plan does not impose age or maximums on autism coverage. |
YES | $40.00 |
100.00% |
| Hearing Aids
To restore or correction of impaired speech or hearing loss. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year |
YES | $80.00 |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
All usual Hospital services and supplies, including semiprivate room, intensive care, and coronary care units; Preauthorization is required. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | 40.00% 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
Preauthorization is required. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Preauthorization is required. |
YES | $40.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $80.00 Copay after deductible |
100.00% |
| Nutritional Counseling
For Diabetes Treatment only. |
YES | $40.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $40.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $40.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $40.00 |
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 primary 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 Primary Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Primary Care provider under a Silver, Gold, or Platinum plan. |
YES | $40.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 40.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Examples of covered services include: Treatment provided for reconstructive surgery following cancer surgery; Reconstruction of the breast on which mastectomy has been performed. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | $40.00 |
100.00% |
| Rehabilitative Speech Therapy
|
YES | $40.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
|
YES | $0.00 |
100.00% |
| Routine Foot Care
|
NO | ||
| Skilled Nursing Facility
Limit: 25.0 Visit(s) per Year |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $80.00 |
100.00% |
| Specialty Drugs
|
YES | $350.00 Copay after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
Certain services require preauthorization. |
YES | $40.00 |
100.00% |
| Transplant
Preauthorization is required. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Though state law only mandates coverage for temporomandibular joint (TMJ) disorders for large group plans and HMOs, the benchmark plan covers TMJ. Therefore, it is considered part of the EHB package for Texas. |
YES | 40.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $60.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | $0.00 |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 40.00% Coinsurance after deductible |
100.00% |
Silver Classic- Standard Health Insurance Plan Variant 20069TX0100052-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.700578499 |
| 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 |
| 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 | TXF001 |
| Formulary URL | URL |
| HIOS Product ID | 20069TX010 |
| 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 | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer Actuarial Value | 70.44% |
| Issuer ID | 20069 |
| 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 | Silver |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | TXN001 |
| 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) | 20069TX0100052-00 |
| Plan Marketing Name | Silver Classic- Standard |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver Classic- Standard |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $20 |
| SBC Scenario, Having a Baby, Deductible | $5,800 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| 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 | TXS001 |
| Source Name | HIOS |
| Plan ID | 20069TX0100052 |
| State Code | TX |
| 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 | 40.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $11600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,800 |
| 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 | $17800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8900 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,900 |
| 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 Silver Classic- Standard Health Insurance Plan, 20069TX0100052
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Classic- Standard, 20069TX0100052 Health Insurance Plan, 20069TX0100052
-
Does Silver Classic- Standard Health Insurance Plan, 20069TX0100052 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20069TX0100052) Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs?
Does (20069TX0100052) Health Insurance Plan, Variant (20069TX0100052-00) have Out Of Country Coverage?
Does (20069TX0100052) Health Insurance Plan, Variant (20069TX0100052-00) have Out of Service Area Coverage?
Does (20069TX0100052) Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Asthma?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Heart disease?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Depression?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Diabetes?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for High blood pressure & high cholesterol?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Low back pain?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Pregnancy?
Does Silver Classic- Standard Health Insurance Plan, Variant (20069TX0100052-00) offer Disease Management Programs for Weight loss programs?
Disclaimer: This is based on the import(Date: Tue, 16 Apr 2024 06:19 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