Standard UHC OCI Gold 500 - 75753DC0030018 Health Insurance Plan
Optimum Choice, Inc. health insurance plan with the Plan ID 75753DC0030018. The plan is called Standard UHC OCI Gold 500.
Based on the data of Health Plan Issuer, this plan has an actuarial value of 81.90% (the percentage of total average costs for covered benefits that a plan will cover). So, on average, you would be responsible for 18.10% of the costs of all covered benefits (according to the Issuer).
| Health Insurance Plan ID | 75753DC0030018 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Health Insurance Plan Year | 2024 | ||||||||||||||||||
| State | District of Columbia | ||||||||||||||||||
| Health Insurance Issuer | Optimum Choice, Inc. | ||||||||||||||||||
| Health Insurance Plan Variant | 75753DC0030018-01 | ||||||||||||||||||
| Provider Network(s) | ['DCN001'] | ||||||||||||||||||
| In Network Doctors
*The data available in our database based on Health Insurance Company Open Data (update: Thu, 21 Nov 2024 00:44 GMT). |
|
||||||||||||||||||
| Available Variants of the Health Plan | |||||||||||||||||||
| Last Plan Update Date | Mon, 12 Feb 2024 00:00 GMT | ||||||||||||||||||
| Last Import Date | Thu, 21 Nov 2024 00:44 GMT |
Standard UHC OCI Gold 500 Health Insurance Plan Variant 75753DC0030018-01 Attributes
| Plan Attribute | Value |
|---|---|
| Business Year | 2024 |
| Child-Only Offering | Allows Adult and Child-Only |
| Composite Rating Offered | No |
| CSR Variation Type | Standard Gold On Exchange Plan |
| Drug EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Drug EHB Deductible, In Network (Tier 1), Default Coinsurance | 0.00% |
| Drug EHB Deductible, In Network (Tier 1), Family | $250 per person | per group not applicable |
| Drug EHB Deductible, In Network (Tier 1), Individual | $250 |
| Drug EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Drug EHB Deductible, Out of Network, Individual | Not Applicable |
| Dental Only Plan | No |
| Disease Management Programs Offered | Pregnancy, Diabetes, Heart Disease |
| First Tier Utilization | 100% |
| Formulary ID | DCF009 |
| HIOS Product ID | 75753DC003 |
| HSA/HRA Employer Contribution | No |
| Import Date | 2/12/2024 |
| Inpatient Copayment Maximum Days | 5 |
| HSA Eligible | No |
| IsItANewPlan | Existing |
| Notice Required for Pregnancy | No |
| Is a Referral Required for Specialist? | Yes |
| Issuer Actuarial Value | 81.90% |
| Issuer ID | 75753 |
| Market Coverage | SHOP (Small Group) |
| Medical Drug Deductibles Integrated | No |
| Medical Drug Maximum Out of Pocket Integrated | Yes |
| Medical EHB Deductible, Combined In/Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Combined In/Out of Network, Individual | Not Applicable |
| Medical EHB Deductible, In Network (Tier 1), Default Coinsurance | 20.00% |
| Medical EHB Deductible, In Network (Tier 1), Family | $500 per person | $1000 per group |
| Medical EHB Deductible, In Network (Tier 1), Individual | $500 |
| Medical EHB Deductible, Out of Network, Family | per person not applicable | per group not applicable |
| Medical EHB Deductible, Out of Network, Individual | Not Applicable |
| Metal Level | Gold |
| Multiple In Network Tiers | No |
| National Network | No |
| Network ID | DCN001 |
| Out of Country Coverage | No |
| Out of Service Area Coverage | No |
| Plan Effective Date | 1/1/2024 |
| Plan ID (Standard Component ID with Variant) | 75753DC0030018-01 |
| Plan Marketing Name | Standard UHC OCI Gold 500 |
| Plan Type | HMO |
| Plan Variant Marketing Name | Standard UHC OCI Gold 500 |
| QHP/Non QHP | On the Exchange |
| SBC Scenario, Having a Baby, Coinsurance | $100 |
| SBC Scenario, Having a Baby, Copayment | $1,500 |
| SBC Scenario, Having a Baby, Deductible | $500 |
| SBC Scenario, Having a Baby, Limit | $60 |
| SBC Scenario, Having Diabetes, Coinsurance | $0 |
| SBC Scenario, Having Diabetes, Copayment | $1,400 |
| SBC Scenario, Having Diabetes, Deductible | $100 |
| SBC Scenario, Having Diabetes, Limit | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Coinsurance | $0 |
| SBC Scenario, Treatment of a Simple Fracture, Copayment | $1,000 |
| SBC Scenario, Treatment of a Simple Fracture, Deductible | $30 |
| SBC Scenario, Treatment of a Simple Fracture, Limit | $0 |
| Service Area ID | DCS001 |
| Source Name | SERFF |
| Specialist Requiring a Referral | All, except OBGYN and as state mandated |
| Plan ID | 75753DC0030018 |
| State Code | DC |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Combined In/Out Network, Individual | Not Applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family | $5800 per person | $11600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $5,800 |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Family | per person not applicable | per group not applicable |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), Out of Network, Individual | Not Applicable |
| Unique Plan Design | Yes |
| Version Number | 1 |
| Wellness Program Offered | No |
Copay & Coinsurance of Standard UHC OCI Gold 500 Health Insurance Plan, 75753DC0030018
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about Standard UHC OCI Gold 500, 75753DC0030018 Health Insurance Plan, 75753DC0030018
-
Does Standard UHC OCI Gold 500 Health Insurance Plan, 75753DC0030018 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (75753DC0030018) Health Insurance Plan, Variant (75753DC0030018-01) offer Disease Management Programs?
Does (75753DC0030018) Health Insurance Plan, Variant (75753DC0030018-01) have Out Of Country Coverage?
Does (75753DC0030018) Health Insurance Plan, Variant (75753DC0030018-01) have Out of Service Area Coverage?
Does (75753DC0030018) Health Insurance Plan, Variant (75753DC0030018-01) offer Disease Management Programs?
Does Standard UHC OCI Gold 500 Health Insurance Plan, Variant (75753DC0030018-01) offer Disease Management Programs for Heart disease?
Does Standard UHC OCI Gold 500 Health Insurance Plan, Variant (75753DC0030018-01) offer Disease Management Programs for Diabetes?
Does Standard UHC OCI Gold 500 Health Insurance Plan, Variant (75753DC0030018-01) offer Disease Management Programs for Pregnancy?
Disclaimer: This is based on the import(Date: Thu, 21 Nov 2024 00:44 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