Silver Simple (Select) - 11574IL0020008 Health Insurance Plan

Oscar Health Plan, Inc. health insurance plan with the Plan ID 11574IL0020008. The plan is called Silver Simple (Select).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 66.64% (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 33.36% 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 11574IL0020008
Health Insurance Plan Year 2022
State Illinois
Health Insurance Issuer Oscar Health Plan, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 11574IL0020008-00
Provider Network(s) ['ILN002']
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 Illinois 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 - 11574IL0020008-00

Standard On Exchange Plan - 11574IL0020008-01

Open to Indians below 300% FPL - 11574IL0020008-02

Open to Indians above 300% FPL - 11574IL0020008-03

73% AV Silver Plan - 11574IL0020008-04

87% AV Silver Plan - 11574IL0020008-05

94% AV Silver Plan - 11574IL0020008-06

Last Plan Update Date Mon, 24 Jan 2022 00:00 GMT
Last Import Date Wed, 27 Mar 2024 12:10 GMT

Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 Attributes

Plan Attribute Value
AV Calculator Output Number 0.666412181
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 Silver 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 0.998003992
First Tier Utilization 20%
Formulary ID ILF001
Formulary URL URL
HIOS Product ID 11574IL002
Import Date 1/24/2022 20:01
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? Yes
Issuer ID 11574
Issuer Marketplace Marketing Name Oscar Health Plan, Inc.
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Silver
Multiple In Network Tiers Yes
National Network No
Network ID ILN002
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) 11574IL0020008-00
Plan Marketing Name Silver Simple (Select)
Plan Type HMO
Plan Variant Marketing Name Silver Simple (Select) ($3 Drugs + $0 Virtual Care)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $3,000
SBC Scenario, Having a Baby, Copayment $200
SBC Scenario, Having a Baby, Deductible $4,200
SBC Scenario, Having a Baby, Limit $50
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $400
SBC Scenario, Having Diabetes, Deductible $4,200
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 ILS002
Source Name SERFF
Specialist Requiring a Referral You may access Covered Services from an In-Network Provider with a Referral from Your Primary Care Physician (PCP). The following Covered Services are available without You having to obtain a Referral from Your PCP: services provided by a Women’s Principal Healthcare Provider, obstetric and gynecological care and related services, In-Network Behavioral Health and Substance Use Disorder services, In-Network Pediatric Dental and Vision services, Urgent and Emergency care.
Plan ID 11574IL0020008
State Code IL
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 50.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $8400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $4200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $4,200
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 $8400 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person $4200 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual $4,200
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 $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,700
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $17400 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $8700 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $8,700
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 Silver Simple (Select) Health Insurance Plan, 11574IL0020008

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

Frequently Asked Questions(FAQ) about Silver Simple (Select), 11574IL0020008 Health Insurance Plan, 11574IL0020008

  • Does Silver Simple (Select) Health Insurance Plan, 11574IL0020008 support Mail Ordering?

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

  • Does (11574IL0020008) Health Insurance Plan, Variant (11574IL0020008-00) 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 (11574IL0020008) Health Insurance Plan, Variant (11574IL0020008-00) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (11574IL0020008) Health Insurance Plan, Variant (11574IL0020008-00) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services Only

    Does (11574IL0020008) Health Insurance Plan, Variant (11574IL0020008-00) 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 Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Asthma?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for Asthma.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Heart disease?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for Heart disease.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Depression?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for Depression.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Diabetes?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for Diabetes.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for High blood pressure & high cholesterol?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for High blood pressure & high cholesterol.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Low back pain?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for Low back pain.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Pregnancy?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 offers Disease Management Program for Pregnancy.

    Does Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan, Variant (11574IL0020008-00) offer Disease Management Programs for Weight loss programs?

    Yes, the Silver Simple (Select) ($3 Drugs + $0 Virtual Care) Health Insurance Plan Variant 11574IL0020008-00 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