UHC Gold Standard+ (Dental + Vision, No Referrals) - 33931OH0070009 Health Insurance Plan

UnitedHealthcare of Ohio, Inc. health insurance plan with the Plan ID 33931OH0070009. The plan is called UHC Gold Standard+ (Dental + Vision, No Referrals).

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 33931OH0070009
Health Insurance Plan Year 2025
State Ohio
Health Insurance Issuer UnitedHealthcare of Ohio, Inc.
Plan Formulary Description URL Formulary URL
Plan Marketing Materials URL Marketing URL
Health Insurance Plan Variant 33931OH0070009-02
Provider Network(s) NETWORK NON-PREFERRED
In Network Doctors

*The data available in our database based on Health Insurance Company Open Data (update: Tue, 10 Dec 2024 06:32 GMT).

Providers Ohio All US States
All 28520 30501
PCP 3459 3585
Allergy 5 5
OB/GYN 108 116
Dentists 36 44
Available Variants of the Health Plan

Standard Off Exchange Plan - 33931OH0070009-00

Standard On Exchange Plan - 33931OH0070009-01

Open to Indians below 300% FPL - 33931OH0070009-02

Open to Indians above 300% FPL - 33931OH0070009-03

Last Plan Update Date Fri, 13 Sep 2024 00:00 GMT
Last Import Date Tue, 10 Dec 2024 06:32 GMT

Benefits of UHC Gold Standard+ (Dental + Vision, No Referrals) Health Insurance Plan, 33931OH0070009-02

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

$0.00, 0.00%

100.00%
Acupuncture
NO
Allergy Testing
YES

$0.00, 0.00%

100.00%
Bariatric Surgery
NO
Basic Dental Care - Adult

Limit: 1000.0 Dollars per Year

1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit

YES

$0.00, 0.00%

100.00%
Basic Dental Care - Child

Benefit limitations may apply to individual services.

YES

$0.00, 0.00%

100.00%
Chemotherapy
YES

$0.00, 0.00%

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

YES

$0.00, 0.00%

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

Childbirth/delivery professional services follow inpatient physician/surgeon fees.

YES

$0.00, 0.00%

100.00%
Dental Check-Up for Children

Limit: 1.0 Exam(s) per 6 Months

YES

$0.00, 0.00%

100.00%
Diabetes Education
YES

$0.00, 0.00%

100.00%
Dialysis
YES

$0.00, 0.00%

100.00%
Durable Medical Equipment
YES

$0.00, 0.00%

100.00%
Emergency Room Services
YES

$0.00, 0.00%

$0.00, 0.00%
Emergency Transportation/Ambulance
YES

$0.00, 0.00%

$0.00, 0.00%
Eye Glasses - Adult

Limit: 1.0 Item(s) per Year

Excluded from In-Network Out-of-Pocket Limit

YES

$0.00, 0.00%

100.00%
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

$0.00, 0.00%

100.00%
Gender Affirming Care

Covered when medically necessary.

YES

$0.00, 0.00%

100.00%
Generic Drugs

Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$0.00, 0.00%

100.00%
Habilitation Services

Limit: 60.0 Visit(s) per Year

Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, and 20 visits per year for Physical Therapy. Visit limits do not apply for therapies for covered persons with a primary diagnosis of Autism Spectrum Disorder.

YES

$0.00, 0.00%

100.00%
Hearing Aids

Cochlear implants are covered as durable medical equipment.

NO
Home Health Care Services

Limit: 100.0 Visit(s) per Year

The 100 visit/year limit is not applicable to home infusion therapy or private duty nursing rendered in the home setting.

YES

$0.00, 0.00%

100.00%
Hospice Services
YES

$0.00, 0.00%

100.00%
Imaging (CT/PET Scans, MRIs)

Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information.

YES

$0.00, 0.00%

100.00%
Infertility Treatment

Exclusions: Health care services and related expenses for infertility treatments, including assisted reproductive technology, in vitro fertilization, in vivo fertilization, or any other medically-aided insemination procedure, regardless of the reason for the treatment, except when performed for the diagnosis, treatment and correction of the underlying causes of infertility.

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). Depending upon where the covered service is provided, benefits will be the same as those stated under each health care service category.

YES

$0.00, 0.00%

100.00%
Infusion Therapy
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Inpatient Physician and Surgical Services
YES

$0.00, 0.00%

100.00%
Laboratory Outpatient and Professional Services

Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information.

YES

$0.00, 0.00%

100.00%
Long-Term/Custodial Nursing Home Care
NO
Major Dental Care - Adult

Limit: 1000.0 Dollars per Year

1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit

YES

$0.00, 0.00%

100.00%
Major Dental Care - Child

Benefit limitations may apply to individual services.

YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Inpatient Services
YES

$0.00, 0.00%

100.00%
Mental/Behavioral Health Outpatient Services

Cost share applies to office visits, please see SBC for Mental Health Outpatient Services.

YES

$0.00, 0.00%

100.00%
Non-Preferred Brand Drugs

Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$0.00, 0.00%

100.00%
Nutritional Counseling

Medical or behavioral/mental health related nutritional education services that are provided as part of treatment for a disease are covered

YES

$0.00, 0.00%

100.00%
Orthodontia - Adult
NO
Orthodontia - Child

Coverage is for medically necessary orthodontia only.

YES

$0.00, 0.00%

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

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
Outpatient Rehabilitation Services

Limit: 60.0 Visit(s) per Year

Limited to 20 visits per year for Speech Therapy, 20 visits per year for Occupational Therapy, 20 visits per year for Physical Therapy, 36 visits per year for Cardiac rehabilitation Therapy, and 20 visits per year for Pulmonary rehabilitation therapy.

YES

$0.00, 0.00%

100.00%
Outpatient Surgery Physician/Surgical Services
YES

$0.00, 0.00%

100.00%
Preferred Brand Drugs

Members can obtain a 1 month supply through network pharmacies or home delivery. Members also have the option to receive a 3 month supply through network pharmacy or home delivery. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$0.00, 0.00%

100.00%
Prenatal and Postnatal Care
YES

$0.00, 0.00%

100.00%
Preventive Care/Screening/Immunization
YES

$0.00, 0.00%

100.00%
Primary Care Visit to Treat an Injury or Illness

Cost sharing for Virtual Primary Care matches in-person office visit.

YES

$0.00, 0.00%

100.00%
Private-Duty Nursing

Limit: 90.0 Visit(s) per Year

Private Duty Nursing Services are Covered Services only when provided through the Home Health Care Services benefit.

YES

$0.00, 0.00%

100.00%
Prosthetic Devices
YES

$0.00, 0.00%

100.00%
Radiation
YES

$0.00, 0.00%

100.00%
Reconstructive Surgery
YES

$0.00, 0.00%

100.00%
Rehabilitative Occupational and Rehabilitative Physical Therapy

Limit: 40.0 Visit(s) per Year

Limited to 20 visits per year for Occupational Therapy and 20 visits per year for Physical Therapy.

YES

$0.00, 0.00%

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year for Speech Therapy

YES

$0.00, 0.00%

100.00%
Routine Dental Services (Adult)

Limit: 2.0 Visit(s) per Year

1,000 annual benefit maximum includes all Dental Services (Routine, Basic and Major) for Adults; Excluded from In-Network Deductible and Out-of-Pocket Limit

YES

$0.00, 0.00%

100.00%
Routine Eye Exam (Adult)

Limit: 1.0 Visit(s) per Year

Benefit also includes 1 pair of eyeglasses or contact lenses every 12 months. Eyeglass lenses have a $25 copay and frames are covered up to $150. Formulary contact lenses are covered in lieu of glasses with a $25 copay.

YES

$0.00, 0.00%

100.00%
Routine Eye Exam for Children

Limit: 1.0 Visit(s) per Year

YES

$0.00, 0.00%

100.00%
Routine Foot Care

Covered when done for the prevention of complications associated with metabolic, neurologic, or peripheral vascular disease

NO
Skilled Nursing Facility

Limit: 90.0 Days per Year

Limit will be 90 days per benefit period for Skilled Nursing Facility. Limits will be 60 days per benefit period for inpatient physical medicine and rehabilitation.

YES

$0.00, 0.00%

100.00%
Specialist Visit
YES

$0.00, 0.00%

100.00%
Specialty Drugs

Specialty medications are limited to a 1-month supply. Other quantity limits may apply. Check the plan's Summary of Benefits or Prescription Drug List for more information.

YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Inpatient Services
YES

$0.00, 0.00%

100.00%
Substance Abuse Disorder Outpatient Services
YES

$0.00, 0.00%

100.00%
Transplant
YES

$0.00, 0.00%

100.00%
Treatment for Temporomandibular Joint Disorders
YES

$0.00, 0.00%

100.00%
Urgent Care Centers or Facilities
YES

$0.00, 0.00%

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

$0.00, 0.00%

100.00%
X-rays and Diagnostic Imaging

Cost sharing may differ based on the location where services are provided. Please refer to the Certificate of Coverage for more information.

YES

$0.00, 0.00%

100.00%

UHC Gold-A Standard+ (Dental + Vision, No Referrals) Health Insurance Plan Variant 33931OH0070009-02 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 Design 1
EHB Percent of Total Premium 0.97900003
First Tier Utilization 100%
Formulary ID OHF035
Formulary URL URL
HIOS Product ID 33931OH007
Import Date 2024-09-13 20:01:37
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? No
Issuer ID 33931
Issuer Marketplace Marketing Name UnitedHealthcare
Market Coverage Individual
Medical Drug Deductibles Integrated Yes
Medical Drug Maximum Out of Pocket Integrated Yes
Metal Level Gold
Multiple In Network Tiers No
National Network No
Network ID OHN011
Out of Country Coverage No
Out of Service Area Coverage Yes
Out of Service Area Coverage Description Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. The Network Area may include select Network providers located in a neighboring state. The plan also covers emergency health care services received outside the service area.
Plan Brochure URL
Plan Effective Date 2025-01-01
Plan ID (Standard Component ID with Variant) 33931OH0070009-02
Plan Level Exclusions Some exclusions may apply. See the applicable Certificate of Coverage for details.
Plan Marketing Name UHC Gold Standard+ (Dental + Vision, No Referrals)
Plan Type HMO
Plan Variant Marketing Name UHC Gold-A Standard+ (Dental + Vision, No Referrals)
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 $60
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
Service Area ID OHS011
Source Name SERFF
Plan ID 33931OH0070009
State Code OH
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, 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), 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 UHC Gold Standard+ (Dental + Vision, No Referrals) Health Insurance Plan, 33931OH0070009

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

Frequently Asked Questions(FAQ) about UHC Gold Standard+ (Dental + Vision, No Referrals), 33931OH0070009 Health Insurance Plan, 33931OH0070009

  • Does UHC Gold Standard+ (Dental + Vision, No Referrals) Health Insurance Plan, 33931OH0070009 support Mail Ordering?

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

  • Does (33931OH0070009) Health Insurance Plan, Variant (33931OH0070009-02) have Out Of Country Coverage?

    No, unfortunately there is no Out Of Country Coverage for this Health Insurance Plan (variant of plan).

    Does (33931OH0070009) Health Insurance Plan, Variant (33931OH0070009-02) have Out of Service Area Coverage?

    Yes. Details: Plan covers eligible expenses provided by a Network Physician or other provider or facility within the Network Area. The Network Area may include select Network providers located in a neighboring state. The plan also covers emergency health care services received outside the service area.

 

Disclaimer: This is based on the import(Date: Tue, 10 Dec 2024 06:32 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