Silver Elite - 40572FL0200016 Health Insurance Plan
Oscar Insurance Company of Florida health insurance plan with the Plan ID 40572FL0200016. The plan is called Silver Elite.
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.64% (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 29.36% 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 | 40572FL0200016 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | Florida | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company of Florida | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 40572FL0200016-00 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 40572FL0200016-00 Standard On Exchange Plan - 40572FL0200016-01 Open to Indians below 300% FPL - 40572FL0200016-02 Open to Indians above 300% FPL - 40572FL0200016-03 73% AV Silver Plan - 40572FL0200016-04 |
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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 Silver Elite Health Insurance Plan, 40572FL0200016-00
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | $150.00 Copay 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 | $350.00 Copay after deductible |
100.00% |
| Chiropractic Care
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $75.00 |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
The per day copayment will apply for a maximum of 2 days. |
YES | $500.00 Copay after deductible |
100.00% |
| Dental Check-Up for Children
|
NO | ||
| Diabetes Education
|
YES | $0.00 |
100.00% |
| Dialysis
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | $750.00 Copay after deductible |
$750.00 Copay after deductible |
| Emergency Transportation/Ambulance
|
YES | $750.00 Copay after deductible |
$750.00 Copay after deductible |
| Eye Glasses for Children
|
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
YES | $500.00 Copay after deductible |
100.00% |
| Generic Drugs
|
YES | Tier 1: $3.00 Tier 2: $25.00 |
100.00% |
| Habilitation Services
Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
YES | $75.00 |
100.00% |
| Hearing Aids
|
NO | ||
| Home Health Care Services
Limit: 20.0 Days per Benefit Period |
YES | $75.00 |
100.00% |
| Hospice Services
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | $200.00 Copay after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
The per day copayment will apply for a maximum of 2 days. |
YES | $500.00 Copay per Day after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | $150.00 Copay after deductible |
100.00% |
| Laboratory Outpatient and Professional Services
|
YES | Tier 1: $10.00 Tier 2: $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
The per day copayment will apply for a maximum of 2 days. |
YES | $500.00 Copay per Day after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
|
YES | $75.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
Diabetes coverage includes 'nutrition counseling'; home health services include 'nutritional guidance.' |
YES | $30.00 |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | $30.00 |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | $350.00 Copay after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $75.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | $150.00 Copay 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
|
YES | Tier 1: $0.00 Tier 2: $30.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
Only for Breast reconstruction following a Mastectomy. |
YES | $500.00 Copay after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $75.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 35.0 Visit(s) per Benefit Period Combined limit for all outpatient therapy plus chiropractic. |
YES | $75.00 |
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: 60.0 Days per Benefit Period The per day copayment will apply for a maximum of 2 days. |
YES | $500.00 Copay per Day after deductible |
100.00% |
| Specialist Visit
|
YES | $75.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
The per day copayment will apply for a maximum of 2 days. |
YES | $500.00 Copay per Day after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $75.00 |
100.00% |
| Transplant
|
YES | $500.00 Copay after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $75.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | $50.00 Copay after deductible |
100.00% |
Silver Elite Health Insurance Plan Variant 40572FL0200016-00 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.7063505904096601 |
| 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 Silver Off Exchange Plan |
| Dental Only Plan | No |
| Design Type | Not Applicable |
| Disease Management Programs Offered | Asthma, Heart Disease, Depression, Diabetes, Pregnancy |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 20% |
| Formulary ID | FLF022 |
| Formulary URL | URL |
| HIOS Product ID | 40572FL020 |
| Import Date | 2023-12-16 01:02:09 |
| Limited Cost Sharing Plan Variation - Estimated Advanced Payment | $0.00 |
| Inpatient Copayment Maximum Days | 2 |
| HSA Eligible | No |
| New/Existing Plan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | No |
| Issuer ID | 40572 |
| Issuer Marketplace Marketing Name | Oscar Insurance Company of Florida |
| 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 | FLN001 |
| 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) | 40572FL0200016-00 |
| Plan Marketing Name | Silver Elite |
| Plan Type | EPO |
| Plan Variant Marketing Name | Silver Elite |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $0 |
| SBC Scenario, Having a Baby, Copayment | $700 |
| SBC Scenario, Having a Baby, Deductible | $5,000 |
| 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 | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $400 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $2,200 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 80% |
| Service Area ID | FLS002 |
| Source Name | HIOS |
| Plan ID | 40572FL0200016 |
| State Code | FL |
| 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 | $10000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $5,000 |
| 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 | $10000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $5000 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $5,000 |
| 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 | $16800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $8400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $8,400 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $16800 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $8400 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $8,400 |
| 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 Elite Health Insurance Plan, 40572FL0200016
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Elite, 40572FL0200016 Health Insurance Plan, 40572FL0200016
-
Does Silver Elite Health Insurance Plan, 40572FL0200016 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (40572FL0200016) Health Insurance Plan, Variant (40572FL0200016-00) offer Disease Management Programs?
Does (40572FL0200016) Health Insurance Plan, Variant (40572FL0200016-00) have Out Of Country Coverage?
Does (40572FL0200016) Health Insurance Plan, Variant (40572FL0200016-00) have Out of Service Area Coverage?
Does (40572FL0200016) Health Insurance Plan, Variant (40572FL0200016-00) offer Disease Management Programs?
Does Silver Elite Health Insurance Plan, Variant (40572FL0200016-00) offer Disease Management Programs for Asthma?
Does Silver Elite Health Insurance Plan, Variant (40572FL0200016-00) offer Disease Management Programs for Heart disease?
Does Silver Elite Health Insurance Plan, Variant (40572FL0200016-00) offer Disease Management Programs for Depression?
Does Silver Elite Health Insurance Plan, Variant (40572FL0200016-00) offer Disease Management Programs for Diabetes?
Does Silver Elite Health Insurance Plan, Variant (40572FL0200016-00) 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