Gold Elite - 23552TN0020036 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 23552TN0020036. The plan is called Gold Elite.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 80.77% (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 19.23% 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 | 23552TN0020036 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Tennessee | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 23552TN0020036-00 | ||||||||||||||||||
| Provider Network(s) | PREFERRED | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Tue, 03 Dec 2024 06:24 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | Standard Off Exchange Plan - 23552TN0020036-00 Standard On Exchange Plan - 23552TN0020036-01 |
||||||||||||||||||
| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Gold Elite Health Insurance Plan, 23552TN0020036-00
| 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 | $75.00 |
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 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 | $75.00 |
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
Durable medical equipment over $500 requires prior authorization. |
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 Benefit Period |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $25.00 |
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 | $75.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: Exclusions: Custodial, domiciliary or private duty nursing services. Skilled Nursing services not received in a Medicare certified skilled nursing facility. |
YES | $75.00 |
100.00% |
| Hospice Services
Exclusions: Inpatient hospice services, unless approved by Case Management. Prior Authorization required for Inpatient Hospice. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
Exclusions: Exclusion: Diagnostic Services not ordered by a Practitioner. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
Exclusions: Services or supplies that are designed to create a pregnancy, enhance fertility or improve conception quality, including but not limited to: artificial insemination, in vitro fertilization. Services or supplies for the evaluation of infertility. |
NO | ||
| Infusion Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
Exclusions: Exclusions: Inpatient stays primarily for therapy (such as physical or occupational therapy). Private room when not Authorized by the Plan and room and board charges are in excess of semi-private room. Services that could be provided in a less intensive setting. |
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
Exclusions: Exclusion: Diagnostic Services not ordered by a Practitioner. |
YES | $30.00 |
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
The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $15.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
For Diabetes Treatment only. |
YES | $15.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $15.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 30.00% Coinsurance after deductible |
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 | $75.00 |
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
Cost share applies to both in-person and telemedicine services. |
YES | $15.00 |
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 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 | 30.00% Coinsurance after deductible |
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 | $75.00 |
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 | $75.00 |
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
Exclusions: Exclusions: Routine foot care for the treatment of: (1) flat feet; (2) corns; (3) bunions; (4) calluses; (5) toenails; (6) fallen arches; and (7) weak feet or chronic foot strain. |
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Year Skilled Nursing and Rehabilitation Facility limited to 60 days/year combined. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Cost share applies to both in-person and telemedicine services. |
YES | $75.00 |
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
The cost sharing that displays applies to outpatient office visits only. All other outpatient services, such as Partial Hospitalization and Intensive Outpatient Program, may be subject to additional cost sharing. Please refer to the plan policy documents for detailed information. |
YES | $15.00 |
100.00% |
| Transplant
Transplant services or supplies that have not received Prior Authorization will not be Covered. |
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
Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full. |
YES | $50.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
Exclusions: Exclusion: Diagnostic Services not ordered by a Practitioner. |
YES | $100.00 |
100.00% |
Gold Elite Health Insurance Plan Variant 23552TN0020036-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8077439019009269 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2025 |
| 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, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 44% |
| Formulary ID | TNF001 |
| Formulary URL | URL |
| HIOS Product ID | 23552TN002 |
| Import Date | 2024-10-17 01:02:25 |
| 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 | Gold |
| 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 | 2025-01-01 |
| Plan Expiration Date | 2025-12-31 |
| Plan ID (Standard Component ID with Variant) | 23552TN0020036-00 |
| Plan Marketing Name | Gold Elite |
| Plan Type | EPO |
| Plan Variant Marketing Name | Gold Elite |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,800 |
| SBC Scenario, Having a Baby, Copayment | $300 |
| 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 | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 56% |
| Service Area ID | TNS001 |
| Source Name | HIOS |
| Plan ID | 23552TN0020036 |
| 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 | 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, 23552TN0020036
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold Elite, 23552TN0020036 Health Insurance Plan, 23552TN0020036
-
Does Gold Elite Health Insurance Plan, 23552TN0020036 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (23552TN0020036) Health Insurance Plan, Variant (23552TN0020036-00) offer Disease Management Programs?
Does (23552TN0020036) Health Insurance Plan, Variant (23552TN0020036-00) have Out Of Country Coverage?
Does (23552TN0020036) Health Insurance Plan, Variant (23552TN0020036-00) have Out of Service Area Coverage?
Does (23552TN0020036) Health Insurance Plan, Variant (23552TN0020036-00) offer Disease Management Programs?
Does Gold Elite Health Insurance Plan, Variant (23552TN0020036-00) offer Disease Management Programs for Asthma?
Does Gold Elite Health Insurance Plan, Variant (23552TN0020036-00) offer Disease Management Programs for Heart disease?
Does Gold Elite Health Insurance Plan, Variant (23552TN0020036-00) offer Disease Management Programs for Depression?
Does Gold Elite Health Insurance Plan, Variant (23552TN0020036-00) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Tue, 03 Dec 2024 06:24 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