UHC Gold Standard (No Referrals) - 33931OH0030014 Health Insurance Plan
UnitedHealthcare of Ohio, Inc. health insurance plan with the Plan ID 33931OH0030014. The plan is called UHC Gold Standard (No Referrals).
Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 78.06% (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 21.94% 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 | 33931OH0030014 | ||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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 | 33931OH0030014-03 | ||||||||||||||||||
| 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). |
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| Available Variants of the Health Plan | Standard Off Exchange Plan - 33931OH0030014-00 Standard On Exchange Plan - 33931OH0030014-01 |
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| 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 (No Referrals) Health Insurance Plan, 33931OH0030014-03
| Benefit | Covered | In Network | Out Of Network |
|---|---|---|---|
| Abortion for Which Public Funding is Prohibited
|
NO | ||
| Accidental Dental
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Acupuncture
|
NO | ||
| Allergy Testing
|
YES | $60.00 |
100.00% |
| Bariatric Surgery
|
NO | ||
| Basic Dental Care - Adult
|
NO | ||
| Basic Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chemotherapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Chiropractic Care
Limit: 12.0 Visit(s) per Benefit Period |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Cosmetic Surgery
|
NO | ||
| Delivery and All Inpatient Services for Maternity Care
Childbirth/delivery professional services follow inpatient physician/surgeon fees. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dental Check-Up for Children
Limit: 1.0 Exam(s) per 6 Months |
YES | No Charge |
100.00% |
| Diabetes Education
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Dialysis
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Durable Medical Equipment
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Emergency Room Services
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Emergency Transportation/Ambulance
|
YES | 25.00% Coinsurance after deductible |
25.00% Coinsurance after deductible |
| Eye Glasses for Children
Limit: 1.0 Item(s) per Year |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Gender Affirming Care
Covered when medically necessary. |
YES | 25.00% Coinsurance after deductible |
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 | $15.00 |
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 | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Hospice Services
|
YES | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Infusion Therapy
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Hospital Services (e.g., Hospital Stay)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Inpatient Physician and Surgical Services
|
YES | 25.00% Coinsurance after deductible |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Long-Term/Custodial Nursing Home Care
|
NO | ||
| Major Dental Care - Adult
|
NO | ||
| Major Dental Care - Child
Benefit limitations may apply to individual services. |
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Mental/Behavioral Health Outpatient Services
Cost share applies to office visits, please see SBC for Mental Health Outpatient Services. |
YES | $30.00 |
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 | $60.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Orthodontia - Adult
|
NO | ||
| Orthodontia - Child
Coverage is for medically necessary orthodontia only. |
YES | 50.00% Coinsurance after deductible |
100.00% |
| Other Practitioner Office Visit (Nurse, Physician Assistant)
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
|
YES | 25.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Outpatient Surgery Physician/Surgical Services
|
YES | 25.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Prenatal and Postnatal Care
|
YES | No Charge |
100.00% |
| Preventive Care/Screening/Immunization
|
YES | 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 | $30.00 |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Prosthetic Devices
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Radiation
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Reconstructive Surgery
|
YES | 25.00% Coinsurance after deductible |
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 | $30.00 |
100.00% |
| Rehabilitative Speech Therapy
Limit: 20.0 Visit(s) per Year Limited to 20 visits per year for Speech Therapy |
YES | $30.00 |
100.00% |
| Routine Dental Services (Adult)
|
NO | ||
| Routine Eye Exam (Adult)
|
NO | ||
| Routine Eye Exam for Children
Limit: 1.0 Visit(s) per Year |
YES | No Charge |
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 | 25.00% Coinsurance after deductible |
100.00% |
| Specialist Visit
|
YES | $60.00 |
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 | $250.00 |
100.00% |
| Substance Abuse Disorder Inpatient Services
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Substance Abuse Disorder Outpatient Services
|
YES | $30.00 |
100.00% |
| Transplant
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Treatment for Temporomandibular Joint Disorders
|
YES | 25.00% Coinsurance after deductible |
100.00% |
| Urgent Care Centers or Facilities
|
YES | $45.00 |
100.00% |
| Weight Loss Programs
|
NO | ||
| Well Baby Visits and Care
|
YES | No Charge |
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 | 25.00% Coinsurance after deductible |
100.00% |
UHC Gold-B Standard (No Referrals) Health Insurance Plan Variant 33931OH0030014-03 Attributes
| Plan Attribute | Value |
|---|---|
| AV Calculator Output Number | 0.78059995 |
| 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 | Limited Cost Sharing Plan Variation |
| Dental Only Plan | No |
| Design Type | Design 1 |
| EHB Percent of Total Premium | 1.0 |
| First Tier Utilization | 100% |
| Formulary ID | OHF035 |
| Formulary URL | URL |
| HIOS Product ID | 33931OH003 |
| 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 | Existing |
| 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) | 33931OH0030014-03 |
| Plan Level Exclusions | Some exclusions may apply. See the applicable Certificate of Coverage for details. |
| Plan Marketing Name | UHC Gold Standard (No Referrals) |
| Plan Type | HMO |
| Plan Variant Marketing Name | UHC Gold-B Standard (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 | 33931OH0030014 |
| 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 | 25.00% |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group | $3000 per group |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person | $1500 per person |
| Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual | $1,500 |
| 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 | $15600 per group |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person | $7800 per person |
| Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual | $7,800 |
| 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 (No Referrals) Health Insurance Plan, 33931OH0030014
| Drug Tier | Pharmacy Type | Copay amount | Copay option | Coinsurance rate | Coinsurance option | Mail Order |
|---|
Frequently Asked Questions(FAQ) about UHC Gold Standard (No Referrals), 33931OH0030014 Health Insurance Plan, 33931OH0030014
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Does UHC Gold Standard (No Referrals) Health Insurance Plan, 33931OH0030014 support Mail Ordering?
Unfortunately, this health insurance plan does not support mail ordering or the plan data in not available.
Does (33931OH0030014) Health Insurance Plan, Variant (33931OH0030014-03) have Out Of Country Coverage?
Does (33931OH0030014) Health Insurance Plan, Variant (33931OH0030014-03) have Out of Service Area Coverage?
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