Silver Simple Chronic Care CKM Guided Care - 20069TX0510060 Health Insurance Plan
Oscar Insurance Company health insurance plan with the Plan ID 20069TX0510060. The plan is called Silver Simple Chronic Care CKM Guided Care.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 87.37% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 12.63% 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 87.15% (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 12.85% 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 | 20069TX0510060 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2025 | ||||||||||||||||||
| State | Texas | ||||||||||||||||||
| Health Insurance Issuer | Oscar Insurance Company | ||||||||||||||||||
| Plan Formulary Description URL | Formulary URL | ||||||||||||||||||
| Plan Marketing Materials URL | Marketing URL | ||||||||||||||||||
| Health Insurance Plan Variant | 20069TX0510060-05 | ||||||||||||||||||
| 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 - 20069TX0510060-00 Standard On Exchange Plan - 20069TX0510060-01 Open to Indians below 300% FPL - 20069TX0510060-02 Open to Indians above 300% FPL - 20069TX0510060-03 73% AV Silver Plan - 20069TX0510060-04 |
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| Last Plan Update Date | Thu, 17 Oct 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
Benefits of Silver Simple Chronic Care CKM Guided Care Health Insurance Plan, 20069TX0510060-05
| 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 | $25.00 |
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: 35.0 Visit(s) per Year Limited to combined 35 visits per year, including Chiropractic. |
YES | $25.00 |
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 cesarean section. |
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
Exclusions: Durable medical equipment not provided for Home Health Care. Rental covered under medical/surgical. Excluded from pharmacy benefits, but permitted for diabetes and self-administered injections. Female contraception and breast pumps covered under medical/surgical benefits. Long-term supplemental oxygen is covered in full for members with COPD and other medical conditions that can be treated with long-term supportive oxygen therapy. Prior authorization for medical necessity may apply. |
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
|
YES | 50.00% |
100.00% |
| Gender Affirming Care
|
NO | ||
| Generic Drugs
Preferred generic drugs, including common prescription generic statins, antiasthmatics, and bronchodilators (inhalers), are covered in full. |
YES | Tier 1: $0.00 Tier 2: $10.00 |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Hearing Aids
To restore or correction of impaired speech or hearing loss. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Home Health Care Services
Limit: 60.0 Visit(s) per Year Exclusions: Benefits will not be provided for Home Health Care for Food or home delivered meals; Social case work or homemaker services; Services provided primarily for Custodial Care; Transportation services; Home Infusion Therapy; and Durable medical equipment. |
YES | $25.00 |
100.00% |
| Hospice Services
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Imaging (CT/PET Scans, MRIs)
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Infertility Treatment
|
NO | ||
| Infusion Therapy
|
YES | 30.00% 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 | 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
Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full. |
YES | $35.00 |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
|
NO | ||
| Mental/Behavioral Health Inpatient Services
Preauthorization is required. |
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. Preauthorization is required. |
YES | $0.00 |
100.00% |
| Non-Preferred Brand Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Nutritional Counseling
|
NO | ||
| 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 | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Rehabilitation Services
Limit: 35.0 Visit(s) per Year Cardiac and pulmonary rehab visits are covered in full. Limited to combined 35 visits per year, including Chiropractic. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Preferred Brand Drugs
|
YES | $60.00 |
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 | $0.00 |
100.00% |
| Private-Duty Nursing
|
NO | ||
| Prosthetic Devices
Medically necessary foot orthotics are not subject to a calendar year maximum. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 30.00% 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 | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Occupational and Rehabilitative Physical Therapy
|
YES | 30.00% Coinsurance after deductible |
100.00% |
| Rehabilitative Speech Therapy
|
YES | 30.00% Coinsurance after deductible |
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 | 30.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
Qualified specialist visits for cardiology, pulmonology, and endocrinology are covered in full. Diabetic eye exams and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services. |
YES | $25.00 |
100.00% |
| Specialty Drugs
|
YES | 50.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Inpatient Services
Preauthorization is required. |
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. Certain services require preauthorization. |
YES | $0.00 |
100.00% |
| Transplant
Preauthorization is required. |
YES | 30.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
Exclusions: Excludes any non-surgical (dental restorations, orthodontics, or physical therapy) or non-diagnostic services or supplies (oral appliances, oral splints, oral orthotics, devices, or prosthetics) provided for the treatment of the temporomandibular joint and all adjacent or related muscles and nerves. 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 | 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 | $45.00 |
100.00% |
| Weight Loss Programs
Certain weight loss services such as nutritional and diet counseling are available through a diabetes management plan, autism benefits, and for adults at higher risk of chronic disease. |
NO | ||
| Well Baby Visits and Care
|
YES | 0.00% |
100.00% |
| X-rays and Diagnostic Imaging
|
YES | 30.00% Coinsurance after deductible |
100.00% |
Silver Simple Chronic Care CKM Guided Care CSR 200 Health Insurance Plan Variant 20069TX0510060-05 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.8715241567609928 |
| 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 | 87% AV Level Silver 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 | 44% |
| Formulary ID | TXF001 |
| Formulary URL | URL |
| HIOS Product ID | 20069TX051 |
| 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 | New |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 87.37% |
| 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 | Yes |
| National Network | No |
| Network ID | TXN002 |
| 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) | 20069TX0510060-05 |
| Plan Marketing Name | Silver Simple Chronic Care CKM Guided Care |
| Plan Type | HMO |
| Plan Variant Marketing Name | Silver Simple Chronic Care CKM Guided Care CSR 200 |
| QHP/Non QHP | Both |
| SBC Scenario, Having a Baby, Coinsurance | $2,100 |
| SBC Scenario, Having a Baby, Copayment | $100 |
| SBC Scenario, Having a Baby, Deductible | $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 | $0 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $500 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $50 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $800 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Second Tier Utilization | 56% |
| Service Area ID | TXS006 |
| Source Name | HIOS |
| Specialist Requiring a Referral | All specialists except Behavioral Health, Obstetrics and Gynecology require a referral |
| Plan ID | 20069TX0510060 |
| 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 | 30.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $1600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $800 |
| 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 | $1600 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Family Per Person | $800 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 2), Individual | $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 | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $3,000 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group | $6000 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person | $3000 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual | $3,000 |
| 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 Simple Chronic Care CKM Guided Care Health Insurance Plan, 20069TX0510060
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Silver Simple Chronic Care CKM Guided Care, 20069TX0510060 Health Insurance Plan, 20069TX0510060
-
Does Silver Simple Chronic Care CKM Guided Care Health Insurance Plan, 20069TX0510060 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (20069TX0510060) Health Insurance Plan, Variant (20069TX0510060-05) offer Disease Management Programs?
Does (20069TX0510060) Health Insurance Plan, Variant (20069TX0510060-05) have Out Of Country Coverage?
Does (20069TX0510060) Health Insurance Plan, Variant (20069TX0510060-05) have Out of Service Area Coverage?
Does (20069TX0510060) Health Insurance Plan, Variant (20069TX0510060-05) offer Disease Management Programs?
Does Silver Simple Chronic Care CKM Guided Care CSR 200 Health Insurance Plan, Variant (20069TX0510060-05) offer Disease Management Programs for Asthma?
Does Silver Simple Chronic Care CKM Guided Care CSR 200 Health Insurance Plan, Variant (20069TX0510060-05) offer Disease Management Programs for Heart disease?
Does Silver Simple Chronic Care CKM Guided Care CSR 200 Health Insurance Plan, Variant (20069TX0510060-05) offer Disease Management Programs for Depression?
Does Silver Simple Chronic Care CKM Guided Care CSR 200 Health Insurance Plan, Variant (20069TX0510060-05) offer Disease Management Programs for Diabetes?
Does Silver Simple Chronic Care CKM Guided Care CSR 200 Health Insurance Plan, Variant (20069TX0510060-05) 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