Silver Simple PCP Saver - 43490KS0010025 Health Insurance Plan

Oscar Insurance Company health insurance plan with the Plan ID 43490KS0010025. The plan is called Silver Simple PCP Saver.

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 94.26% (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 5.74% 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 43490KS0010025
Health Insurance Plan Year 2024
State Kansas
Health Insurance Issuer Oscar Insurance Company
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 43490KS0010025-06
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 Kansas All US States
All 2 7
PCP 1 2
Allergy N/A N/A
OB/GYN N/A N/A
Dentists N/A N/A
Available Variants of the Health Plan

Standard Off Exchange Plan - 43490KS0010025-00

Standard On Exchange Plan - 43490KS0010025-01

Open to Indians below 300% FPL - 43490KS0010025-02

Open to Indians above 300% FPL - 43490KS0010025-03

73% AV Silver Plan - 43490KS0010025-04

87% AV Silver Plan - 43490KS0010025-05

94% AV Silver Plan - 43490KS0010025-06

Last Plan Update Date Mon, 18 Dec 2023 00:00 GMT
Last Import Date Tue, 03 Dec 2024 06:24 GMT

Benefits of Silver Simple PCP Saver Health Insurance Plan, 43490KS0010025-06

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

Oral Surgical Services and Services for Accidental Injuries to Sound Natural Teeth, limited to: (1) Surgical procedures of the jaw and gums. (2) Removal of tumors and cysts of the jaws, cheeks, lips, tongue, roof and floor of the mouth. (3) Removal of exostoses (bony growths) of the jaw and hard palate. (4) Treatment of fractures and dislocations of the jaw and facial bones. (5) Surgical removal of impacted teeth. (6) Treatment of Sound Natural Teeth caused by an Accidental Injury. This includes replacement of Sound Natural Teeth lost due to the Accidental Injury. (7) Intra oral dental imaging services in connection with covered oral surgery if treatment begins within 30 days. (8) General anesthesia for covered oral surgery. (9) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants and the associated fixed and/or removable prosthetic appliance when provided because of an Accidental Injury. (10) Cylindrical endosseous dental implants, mandibular staple implants, subperiosteal implants andthe associated fixed and/or removable prosthetic appliances following surgical resection of either benign or malignant lesions (NOT including inflammatory lesions).

YES

20.00%

100.00%
Acupuncture
NO
Allergy Testing

Allergy testing and treatment.

YES

$10.00

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

20.00%

100.00%
Chiropractic Care
YES

$10.00

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

Also covers surrogate mother if there is a petition to adopt within 90 days of birth. See plan documents for separate professional services cost shares.

YES

20.00%

100.00%
Dental Check-Up for Children
NO
Diabetes Education

Outpatient self-management training and education, including medical nutrition therapy, for insulin dependent diabetes, insulin-using diabetes, gestational diabetes and noninsulin using diabetes when provided by a certified, registered or licensed health care professional with expertise in diabetes and the diabetic (1) is treated at a program approved by the American Diabetes Association; (2) is treated by a person certified by the national certification board of diabetes educators; or (3) is, as to nutritional education, treated by a licensed dietitian pursuant to a treatment plan authorized by such healthcare professional.

YES

$0.00

100.00%
Dialysis

Plan cover Hemodialysis.

YES

20.00%

100.00%
Durable Medical Equipment

Benefits are limited to the amount normally available for a basic (standard) item which allows necessary function. Basic (standard) medical equipment is equipment that provides the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level. Charges for deluxe or electrically operated medical equipment are not covered, beyond the extent allowed for basic (standard) items. Deluxe describes medical equipment that has enhancements that allow for additional convenience or use beyond that provided by basic (standard) equipment.

YES

20.00%

100.00%
Emergency Room Services
YES

20.00%

20.00%
Emergency Transportation/Ambulance

Emergency transportation/ambulance within 500 mile radius.

YES

20.00%

20.00%
Eye Glasses for Children
YES

50.00%

100.00%
Gender Affirming Care
YES

20.00%

100.00%
Generic Drugs
YES

Tier 1: $0.00

Tier 2: $5.00

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

20.00%

100.00%
Hearing Aids
NO
Home Health Care Services

Includes educational visits with a limit of three per year on educational visits.

YES

$10.00

100.00%
Hospice Services
YES

20.00%

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

20.00%

100.00%
Infertility Treatment

Plan covers Diagnosis and treatment of cause of infertility. Benefits are available for covered services such as office visits, laboratory tests, and radiological studies to diagnose the cause of infertility. Benefits are also provided for the necessary treatment of the condition unless the treatment is identified as non-covered (see exclusions). For example, corrective surgical procedures, therapeutic injections, and drug therapy regimens (Pregnyl, Clomid, Clomiphene, Ovidrel, Gonal, Follistim and Cetrotide) are all covered services when medically necessary. Benefits are also available for tests, such as ultrasound, performed to monitor the effectiveness of the fertility drug therapy. Also for any necessary pregnancy testing performed as an integral part of the overall infertility treatment program. Benefits are excluded, however, for any procedures, tests, or other services that are exclusively provided to monitor the effectiveness of non-covered fertilization procedures.

YES

20.00%

100.00%
Infusion Therapy
YES

20.00%

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

20.00%

100.00%
Inpatient Physician and Surgical Services
YES

20.00%

100.00%
Laboratory Outpatient and Professional Services
YES

Tier 1: $0.00

Tier 2: 20.00%

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

20.00%

100.00%
Mental/Behavioral Health Outpatient Services
YES

$5.00

100.00%
Non-Preferred Brand Drugs
YES

20.00%

100.00%
Nutritional Counseling
NO
Orthodontia - Adult
NO
Orthodontia - Child

Orthodontic services require prior authorization and are only covered for eligible children with cases of severe orthodontic abnormality caused by genetic deformity (such as cleft lip or cleft palate) or traumatic facial injury resulting in serious health impairment to the beneficiary at the present time.

YES

20.00%

100.00%
Other Practitioner Office Visit (Nurse, Physician Assistant)

Professional Providers include Physician Assistants. Registered Nurses qualify as Eligible Providers.

YES

$5.00

100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
YES

20.00%

100.00%
Outpatient Rehabilitation Services

Limit: 90.0 Days per Benefit Period

These therapies include but are not limited to PT, OT, and ST. Further, '(Rehab) services are covered only if they are expected to result in significant improvement in the Insured's condition. The Company, with appropriate medical consultation, will determine whether significant improvement has occurred'. 'Speech Therapy', limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.

YES

20.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

20.00%

100.00%
Preferred Brand Drugs
YES

$30.00

100.00%
Prenatal and Postnatal Care

Also covers surrogate mother if there is a petition to adopt within 90 days of birth.

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 virtual services.

YES

$5.00

100.00%
Private-Duty Nursing
YES

$10.00

100.00%
Prosthetic Devices

Benefits are limited to the amount normally available for a basic (standard) appliance which allows necessary function. Basic (standard) medical devices or appliances are those that provide the essential function required for the treatment or amelioration of the medical condition at a Medically Necessary level.

YES

20.00%

100.00%
Radiation
YES

20.00%

100.00%
Reconstructive Surgery

Cosmetic and reconstructive are generally excluded, but excepted from this exclusion are: a. Cosmetic or reconstructive repair of an Accidental Injury.; b. Reconstructive breast surgery in connection with a Medically Necessary mastectomy that resulted from a medical illness or injury. This includes reconstructive surgery on a breast on which a mastectomy was not performed in order to produce a symmetrical appearance.; c. Repair of congenital abnormalities and hereditary complications or conditions, limited to: (1) Cleft lip or palate. (2) Birthmarks on head or neck. (3) Webbed fingers or toes. (4) Supernumerary fingers or toes.; d. Reconstructive services performed on structures of the body to improve/restore impairments of bodily function resulting from disease, trauma, congenital or developmental anomalies or previous therapeutic processes. For purposes of this provision, the term 'cosmetic' means procedures and related services performed to reshape structures of the body in order to alter the individual's appearance.

YES

20.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy
YES

20.00%

100.00%
Rehabilitative Speech Therapy

Limit: 90.0 Days per Benefit Period

Limited to one service per day up to a maximum benefit of 90 daily services per Insured per Benefit Period. This limitation is not applicable to Mental Illness or Substance Use Disorders.

YES

20.00%

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

Covered when systemic conditions such as metabolic, neurologic, or peripheral vascular disease exists and results in medically significant circulatory deficits or decreased sensation to the foot.

YES

$10.00

100.00%
Skilled Nursing Facility
NO
Specialist Visit

Cost share applies to both in-person and virtual services.

YES

$10.00

100.00%
Specialty Drugs
YES

20.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

20.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$5.00

100.00%
Transplant

Benefits are provided for the following human organ transplants: Cornea; heart; heart-lung; kidney; pancreas; liver; lung (whole or lobar, single or double); small intestine; and multivisceral transplants.

YES

20.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

20.00%

100.00%
Urgent Care Centers or Facilities
YES

$30.00

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

0.00%

100.00%
X-rays and Diagnostic Imaging
YES

20.00%

100.00%

Silver Simple PCP Saver CSR 150 Health Insurance Plan Variant 43490KS0010025-06 Attributes

Plan Attribute Value
AV Calculator Output Number 0.9426028970452379
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 94% AV Level Silver 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 KSF001
Formulary URL URL
HIOS Product ID 43490KS001
Import Date 2023-12-18 20:02:01
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 43490
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 KSN001
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) 43490KS0010025-06
Plan Marketing Name Silver Simple PCP Saver
Plan Type EPO
Plan Variant Marketing Name Silver Simple PCP Saver CSR 150
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $1,600
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 $20
SBC Scenario, Having Diabetes, Copayment $800
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 $20
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 KSS001
Source Name SERFF
Plan ID 43490KS0010025
State Code KS
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 $3100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $1550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $1,550
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Group $3100 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Family Per Person $1550 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 2), Individual $1,550
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 Simple PCP Saver Health Insurance Plan, 43490KS0010025

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

Frequently Asked Questions(FAQ) about Silver Simple PCP Saver, 43490KS0010025 Health Insurance Plan, 43490KS0010025

  • Does Silver Simple PCP Saver Health Insurance Plan, 43490KS0010025 support Mail Ordering?

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

  • Does (43490KS0010025) Health Insurance Plan, Variant (43490KS0010025-06) offer Disease Management Programs?

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

    Does (43490KS0010025) Health Insurance Plan, Variant (43490KS0010025-06) have Out Of Country Coverage?

    Yes. Details: Emergency Services Only

    Does (43490KS0010025) Health Insurance Plan, Variant (43490KS0010025-06) have Out of Service Area Coverage?

    Yes. Details: Emergency and Urgent Services only

    Does (43490KS0010025) Health Insurance Plan, Variant (43490KS0010025-06) offer Disease Management Programs?

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

    Does Silver Simple PCP Saver CSR 150 Health Insurance Plan, Variant (43490KS0010025-06) offer Disease Management Programs for Asthma?

    Yes, the Silver Simple PCP Saver CSR 150 Health Insurance Plan Variant 43490KS0010025-06 offers Disease Management Program for Asthma.

    Does Silver Simple PCP Saver CSR 150 Health Insurance Plan, Variant (43490KS0010025-06) offer Disease Management Programs for Heart disease?

    Yes, the Silver Simple PCP Saver CSR 150 Health Insurance Plan Variant 43490KS0010025-06 offers Disease Management Program for Heart disease.

    Does Silver Simple PCP Saver CSR 150 Health Insurance Plan, Variant (43490KS0010025-06) offer Disease Management Programs for Depression?

    Yes, the Silver Simple PCP Saver CSR 150 Health Insurance Plan Variant 43490KS0010025-06 offers Disease Management Program for Depression.

    Does Silver Simple PCP Saver CSR 150 Health Insurance Plan, Variant (43490KS0010025-06) offer Disease Management Programs for Pregnancy?

    Yes, the Silver Simple PCP Saver CSR 150 Health Insurance Plan Variant 43490KS0010025-06 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