Gold Elite Saver Plus - 69803NC0010035 Health Insurance Plan
Oscar Health Plan of North Carolina, Inc health insurance plan with the Plan ID 69803NC0010035. The plan is called Gold Elite Saver Plus.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 79.62% (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 20.38% 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 | 69803NC0010035 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | North Carolina | ||||||||||||||||||
| Health Insurance Issuer | Oscar Health Plan of North Carolina, Inc | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 69803NC0010035-01 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 69803NC0010035-00 Standard On Exchange Plan - 69803NC0010035-01 |
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| Last Plan Update Date | Sat, 16 Dec 2023 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Gold Elite Saver Plus Health Insurance Plan, 69803NC0010035-01
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $200.00 |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $25.00 |
100.00% |
| Bariatric Surgery
For surgical treatment of morbid obesity. |
YES | $1,000.00 |
100.00% |
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
|
NO | ||
| Chemotherapy
|
YES | $200.00 |
100.00% |
| Chiropractic Care
Limit: 30.0 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic). |
YES | $25.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of 3 days. See plan documents for separate professional services cost shares. |
YES | $1,000.00 |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | $200.00 |
100.00% |
| Durable Medical Equipment
Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime. |
YES | 20.00% |
100.00% |
| Emergency Room Services
|
YES | $500.00 |
$500.00 |
| Emergency Transportation/Ambulance
|
YES | $500.00 |
$500.00 |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Benefit Period |
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | $1,000.00 |
100.00% |
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $10.00 |
100.00% |
| Habilitation Services
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | $25.00 |
100.00% |
| Hearing Aids
Limit: 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months. |
YES | 20.00% |
100.00% |
| Home Health Care Services
|
YES | $25.00 |
100.00% |
| Hospice Services
Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
YES | 20.00% |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $375.00 |
100.00% |
| Infertility Treatment
Limit: 3.0 Treatment(s) per Lifetime Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. |
YES | 20.00% |
100.00% |
| Infusion Therapy
|
YES | 20.00% |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $200.00 |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $0.00 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
The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | $220.00 |
100.00% |
| Nutritional Counseling
Nutritional counseling visits are separate from the obesity-related office visits. |
YES | $0.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
NO | ||
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $0.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $500.00 |
100.00% |
| Outpatient Rehabilitation Services
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | $25.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $200.00 |
100.00% |
| Preferred Brand Drugs
|
YES | $75.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | 0.00% |
100.00% |
| Preventive Care/Screening/Immunization
All preventive care that is not state mandated is not covered OON. |
YES | 0.00% |
100.00% |
| Primary Care Visit to Treat an Injury or Illness
Cost share applies to both in-person and virtual services. |
YES | $0.00 |
100.00% |
| Private-Duty Nursing
|
YES | $25.00 |
100.00% |
| Prosthetic Devices
Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery. |
YES | 20.00% |
100.00% |
| Radiation
|
YES | 20.00% |
100.00% |
| Reconstructive Surgery
Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
YES | $1,000.00 |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
YES | $25.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 30.0 Visit(s) per Benefit Period |
YES | $25.00 |
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
|
NO | ||
| Skilled Nursing Facility
Limit: 60.0 Days per Benefit Period The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Specialist Visit
Cost share applies to both in-person and virtual services. |
YES | $25.00 |
100.00% |
| Specialty Drugs
|
YES | $550.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
The per day copayment will apply for a maximum of 3 days. |
YES | $1000.00 Copay per Day |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $0.00 |
100.00% |
| Transplant
Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient's coverage. |
YES | $1,000.00 |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY. |
YES | 20.00% |
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 Saver Plus Health Insurance Plan Variant 69803NC0010035-01 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.796172617967225 |
| Begin Primary Care Cost-Sharing After Number Of Visits | 0 |
| Begin Primary Care Deductible Coinsurance After Number Of Copays | 0 |
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On 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 | 20% |
| Formulary ID | NCF001 |
| Formulary URL | URL |
| HIOS Product ID | 69803NC001 |
| Import Date | 2023-12-16 01:02:09 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 3 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 69803 |
| Issuer Marketplace Marketing Name | Oscar Health Plan of North Carolina, Inc |
| 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 | NCN001 |
| 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 | 2024-01-01 |
| Plan Expiration Date | 2024-12-31 |
| Plan ID (Standard Component ID with Variant) | 69803NC0010035-01 |
| Plan Marketing Name | Gold Elite Saver Plus |
| Plan Type | HMO |
| Plan Variant Marketing Name | Gold Elite Saver Plus |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $1,600 |
| SBC Scenario, Having a Baby, Deductible | $0 |
| SBC Scenario, Having a Baby, Limit | $0 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,700 |
| SBC Scenario, Having Diabetes, Deductible | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,300 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | NCS001 |
| Source Name | HIOS |
| Plan ID | 69803NC0010035 |
| State Code | NC |
| 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 | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $0 |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Default Coinsurance | 20.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Group | $0 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $0 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $0 |
| 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 Gold Elite Saver Plus Health Insurance Plan, 69803NC0010035
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Gold Elite Saver Plus, 69803NC0010035 Health Insurance Plan, 69803NC0010035
-
Does Gold Elite Saver Plus Health Insurance Plan, 69803NC0010035 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (69803NC0010035) Health Insurance Plan, Variant (69803NC0010035-01) offer Disease Management Programs?
Does (69803NC0010035) Health Insurance Plan, Variant (69803NC0010035-01) have Out Of Country Coverage?
Does (69803NC0010035) Health Insurance Plan, Variant (69803NC0010035-01) have Out of Service Area Coverage?
Does (69803NC0010035) Health Insurance Plan, Variant (69803NC0010035-01) offer Disease Management Programs?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (69803NC0010035-01) offer Disease Management Programs for Asthma?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (69803NC0010035-01) offer Disease Management Programs for Heart disease?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (69803NC0010035-01) offer Disease Management Programs for Depression?
Does Gold Elite Saver Plus Health Insurance Plan, Variant (69803NC0010035-01) 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