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 | ||||||||||||||||||
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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). |
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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 |
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Last Plan Update Date | Mon, 18 Dec 2023 00:00 GMT | ||||||||||||||||||
Last Import Date | Tue, 03 Dec 2024 06:24 GMT |
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% |
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 |
Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
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Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
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