Silver Simple Diabetes - 57424NE0010045 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 57424NE0010045. The plan is called Silver Simple Diabetes.

Based on the data of Health Plan Issuer, this plan has an actuarial value of 100.00% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 0.00% 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 100.00% (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 0.00% 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 57424NE0010045
Health Insurance Plan Year 2025
State Nebraska
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 57424NE0010045-02
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).

Providers Nebraska All US States
All 12229 83962
PCP 1526 2444
Allergy 5 8
OB/GYN 48 71
Dentists 5 7
Available Variants of the Health Plan

Standard Off Exchange Plan - 57424NE0010045-00

Standard On Exchange Plan - 57424NE0010045-01

Open to Indians below 300% FPL - 57424NE0010045-02

Open to Indians above 300% FPL - 57424NE0010045-03

73% AV Silver Plan - 57424NE0010045-04

87% AV Silver Plan - 57424NE0010045-05

94% AV Silver Plan - 57424NE0010045-06

Last Plan Update Date Thu, 10 Oct 2024 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Silver Simple Diabetes Health Insurance Plan, 57424NE0010045-02

Benefit Covered In Network Out Of Network
Abortion for Which Public Funding is Prohibited
NO
Accidental Dental

Exclusions: Benefits are limited to treatment provided within 12 months of the injury. Benefits are not available for orthodontics or dental implants. Benefits shall not be provided for such Services when the Injury occurs as the result of eating, biting or chewing.

YES

$0.00

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult
NO
Basic Dental Care - Child
NO
Chemotherapy
YES

$0.00

100.00%
Chiropractic Care

Limit: 20.0 Visit(s) per Year

Chiropractic physiotherapy has a combined limit with PT, OT and speech therapies of 45 sessions per calendar year. Chiropractic manipulative adjustments have a combined limit with osteopathic physiotherapy of 20 sessions per calendar year

YES

$0.00

100.00%
Cosmetic Surgery
NO
Delivery and All Inpatient Services for Maternity Care
YES

$0.00

100.00%
Dental Check-Up for Children
NO
Diabetes Education
YES

$0.00

100.00%
Dialysis
YES

$0.00

100.00%
Durable Medical Equipment
YES

$0.00

100.00%
Emergency Room Services
YES

$0.00

$0.00
Emergency Transportation/Ambulance
YES

$0.00

$0.00
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00

100.00%
Gender Affirming Care
NO
Generic Drugs

Preferred generic drugs are covered in full.

YES

Tier 1: $0.00

Tier 2: $0.00

100.00%
Habilitation Services

Limit: 45.0 Treatment(s) per Year

Exclusions: Autism exclusions: Services for treatment of autism spectrum disorders, including but not limited to applied behavioral analysis and early intensive behavioral intervention. Services for autism spectrum disorders or pervasive developmental conditions, developmental delays or sensory integration disorders unless otherwise required by law or specifically covered elsewhere in this Contract.

Health care Services that help a person keep, learn, or improve skills and functioning for daily living. 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. Quantitative limits on services apply to outpatient, only.

YES

$0.00

100.00%
Hearing Aids
NO
Home Health Care Services

Limit: 60.0 Days per Year

YES

$0.00

100.00%
Hospice Services

The Covered Person must have a life expectancy of six months or less as documented in writing by the attending Physician. The Hospice Services must be ordered by a Physician. Services provided must be appropriate for palliative support or management of a Covered Person with terminal medical Illness.

YES

$0.00

100.00%
Imaging (CT/PET Scans, MRIs)
YES

$0.00

100.00%
Infertility Treatment
NO
Infusion Therapy
YES

$0.00

100.00%
Inpatient Hospital Services (e.g., Hospital Stay)
YES

$0.00

100.00%
Inpatient Physician and Surgical Services
YES

$0.00

100.00%
Laboratory Outpatient and Professional Services

Labs (HbA1c screening, urinalysis, metabolic panel, lipid panel) to manage diabetes are covered in full.

YES

$0.00

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult
NO
Major Dental Care - Child
NO
Mental/Behavioral Health Inpatient Services

Exclusions: Excludes programs that treat obesity or gambling addiction and residential treatment programs. Exclusions include: programs for co-dependency; employee assistance; probation; prevention; educational or self-help; programs which treat obesity, gambling, or nicotine addiction; Custodial Care for Mental Illness and/or Substance Dependence and Abuse; halfway house or Substance Dependence and Abuse maintenance programs; programs ordered by the Court determined to be not Medically Necessary.

YES

$0.00

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

$0.00

100.00%
Non-Preferred Brand Drugs
YES

$0.00

100.00%
Nutritional Counseling
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

$0.00

100.00%
Outpatient Rehabilitation Services

Limit: 45.0 Treatment(s) per Year

Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year)

YES

$0.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00

100.00%
Preferred Brand Drugs
YES

$0.00

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
YES

$0.00

100.00%
Radiation
YES

$0.00

100.00%
Reconstructive Surgery

Available only post-mastectomy or when required to restore, reconstruct or correct any bodily function that was lost, impaired or damaged as a result of Injury or Illness.

YES

$0.00

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 45.0 Visit(s) per Year

Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year)

YES

$0.00

100.00%
Rehabilitative Speech Therapy

Limit: 45.0 Visit(s) per Year

Limits apply to rehabilitation and habilitation combined: Physical, occupational or speech therapy services, chiropractic or osteopathic physiotherapy (combined limit to 45 sessions per Calendar Year)

YES

$0.00

100.00%
Routine Dental Services (Adult)
NO
Routine Eye Exam (Adult)
NO
Routine Eye Exam for Children

Limit: 1.0 Exam(s) per Year

YES

$0.00

100.00%
Routine Foot Care
NO
Skilled Nursing Facility

Limit: 60.0 Days per Year

Exclusions: Skilled nursing facility care does not include: a) supportive Services for a stabilized condition; b) care which can be learned and given by unlicensed or uncertified medical personnel; c) routine health care Services; d) general maintenance or supervision of routine daily activities; or e) routine administration of oral or nonprescription drugs

YES

$0.00

100.00%
Specialist Visit

Diabetic eye exams and diabetic foot exams are covered in full. Cost share applies to both in-person and telemedicine services.

YES

$0.00

100.00%
Specialty Drugs
YES

$0.00

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00

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

$0.00

100.00%
Transplant
YES

$0.00

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00

100.00%
Urgent Care Centers or Facilities

Virtual urgent care services provided by Oscar-designated virtual care providers are covered in full.

YES

$0.00

100.00%
Weight Loss Programs
NO
Well Baby Visits and Care
YES

0.00%

100.00%
X-rays and Diagnostic Imaging
YES

$0.00

100.00%

AIAN Cost Share Health Insurance Plan Variant 57424NE0010045-02 Attributes

Plan Attribute Value
AV Calculator Output Number 1.0
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 Zero Cost Sharing Plan Variation
Dental Only Plan No
Design Type Not Applicable
Disease Management Programs Offered Asthma, Heart Disease, Depression, Diabetes, Pregnancy
EHB Percent of Total Premium 0.9999
First Tier Utilization 44%
Formulary ID NEF001
Formulary URL URL
HIOS Product ID 57424NE001
Import Date 2024-10-10 20:01:47
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 Actuarial Value 100.00%
Issuer ID 57424
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 NEN001
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) 57424NE0010045-02
Plan Marketing Name Silver Simple Diabetes
Plan Type EPO
Plan Variant Marketing Name AIAN Cost Share
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $0
SBC Scenario, Having a Baby, Copayment $0
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 $0
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 $0
SBC Scenario, Treatment of a Simple Fracture, Deductible $0
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Second Tier Utilization 56%
Service Area ID NES001
Source Name SERFF
Plan ID 57424NE0010045
State Code NE
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 0.00%
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 0.00%
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 $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $0
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $0 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $0 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $0
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 Diabetes Health Insurance Plan, 57424NE0010045

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

Frequently Asked Questions(FAQ) about Silver Simple Diabetes, 57424NE0010045 Health Insurance Plan, 57424NE0010045

  • Does Silver Simple Diabetes Health Insurance Plan, 57424NE0010045 support Mail Ordering?

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

  • Does (57424NE0010045) Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does (57424NE0010045) Health Insurance Plan, Variant (57424NE0010045-02) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (57424NE0010045) Health Insurance Plan, Variant (57424NE0010045-02) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services Only

    Does (57424NE0010045) Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs?

    Yes, and here is the list of available programs: Asthma, Heart Disease, Depression, Diabetes, Pregnancy

    Does AIAN Cost Share Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs for Asthma?

    Yes, the AIAN Cost Share Health Insurance Plan Variant 57424NE0010045-02 offers Disease Management Program for Asthma.

    Does AIAN Cost Share Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs for Heart disease?

    Yes, the AIAN Cost Share Health Insurance Plan Variant 57424NE0010045-02 offers Disease Management Program for Heart disease.

    Does AIAN Cost Share Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs for Depression?

    Yes, the AIAN Cost Share Health Insurance Plan Variant 57424NE0010045-02 offers Disease Management Program for Depression.

    Does AIAN Cost Share Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs for Diabetes?

    Yes, the AIAN Cost Share Health Insurance Plan Variant 57424NE0010045-02 offers Disease Management Program for Diabetes.

    Does AIAN Cost Share Health Insurance Plan, Variant (57424NE0010045-02) offer Disease Management Programs for Pregnancy?

    Yes, the AIAN Cost Share Health Insurance Plan Variant 57424NE0010045-02 offers Disease Management Program 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