UHC Silver Standard (No Referrals) - 33931OH0030021 Health Insurance Plan

UnitedHealthcare of Ohio, Inc. health insurance plan with the Plan ID 33931OH0030021. The plan is called UHC Silver Standard (No Referrals).

Based on the AV Calculator by CMS.gov, the plan has an actuarial value of 70.01% (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 29.99% 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 33931OH0030021
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 33931OH0030021-01
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 - 33931OH0030021-00

Standard On Exchange Plan - 33931OH0030021-01

Open to Indians below 300% FPL - 33931OH0030021-02

Open to Indians above 300% FPL - 33931OH0030021-03

73% AV Silver Plan - 33931OH0030021-04

87% AV Silver Plan - 33931OH0030021-05

94% AV Silver Plan - 33931OH0030021-06

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

Benefits of UHC Silver Standard (No Referrals) Health Insurance Plan, 33931OH0030021-01

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

40.00% Coinsurance after deductible

100.00%
Acupuncture
NO
Allergy Testing
YES

$80.00

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

Benefit limitations may apply to individual services.

YES

40.00% Coinsurance after deductible

100.00%
Chemotherapy
YES

40.00% Coinsurance after deductible

100.00%
Chiropractic Care

Limit: 12.0 Visit(s) per Benefit Period

YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

100.00%
Dialysis
YES

40.00% Coinsurance after deductible

100.00%
Durable Medical Equipment
YES

40.00% Coinsurance after deductible

100.00%
Emergency Room Services
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Emergency Transportation/Ambulance
YES

40.00% Coinsurance after deductible

40.00% Coinsurance after deductible
Eye Glasses for Children

Limit: 1.0 Item(s) per Year

YES

40.00% Coinsurance after deductible

100.00%
Gender Affirming Care

Covered when medically necessary.

YES

40.00% 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

$20.00

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

$40.00

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

40.00% Coinsurance after deductible

100.00%
Hospice Services
YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

100.00%
Infusion Therapy
YES

40.00% Coinsurance after deductible

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

40.00% Coinsurance after deductible

100.00%
Inpatient Physician and Surgical Services
YES

40.00% 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

40.00% 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

40.00% Coinsurance after deductible

100.00%
Mental/Behavioral Health Inpatient Services
YES

40.00% 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

$40.00

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

$80.00 Copay after deductible

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

40.00% 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

40.00% Coinsurance after deductible

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

40.00% 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

$40.00

100.00%
Outpatient Surgery Physician/Surgical Services
YES

40.00% 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

$40.00

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

$40.00

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

40.00% Coinsurance after deductible

100.00%
Prosthetic Devices
YES

40.00% Coinsurance after deductible

100.00%
Radiation
YES

40.00% Coinsurance after deductible

100.00%
Reconstructive Surgery
YES

40.00% 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

$40.00

100.00%
Rehabilitative Speech Therapy

Limit: 20.0 Visit(s) per Year

Limited to 20 visits per year for Speech Therapy

YES

$40.00

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

40.00% Coinsurance after deductible

100.00%
Specialist Visit
YES

$80.00

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

$350.00 Copay after deductible

100.00%
Substance Abuse Disorder Inpatient Services
YES

40.00% Coinsurance after deductible

100.00%
Substance Abuse Disorder Outpatient Services
YES

$40.00

100.00%
Transplant
YES

40.00% Coinsurance after deductible

100.00%
Treatment for Temporomandibular Joint Disorders
YES

40.00% Coinsurance after deductible

100.00%
Urgent Care Centers or Facilities
YES

$60.00

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

40.00% Coinsurance after deductible

100.00%

UHC Silver Standard (No Referrals) Health Insurance Plan Variant 33931OH0030021-01 Attributes

Plan Attribute Value
AV Calculator Output Number 0.7001
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 Standard Silver On Exchange Plan
Dental Only Plan No
Design Type Design 1
EHB Percent of Total Premium 1.0
First Tier Utilization 100%
Formulary ID OHF031
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 Silver
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) 33931OH0030021-01
Plan Level Exclusions Some exclusions may apply. See the applicable Certificate of Coverage for details.
Plan Marketing Name UHC Silver Standard (No Referrals)
Plan Type HMO
Plan Variant Marketing Name UHC Silver Standard (No Referrals)
QHP/Non QHP Both
SBC Scenario, Having a Baby, Coinsurance $2,500
SBC Scenario, Having a Baby, Copayment $0
SBC Scenario, Having a Baby, Deductible $5,000
SBC Scenario, Having a Baby, Limit $60
SBC Scenario, Having Diabetes, Coinsurance $0
SBC Scenario, Having Diabetes, Copayment $300
SBC Scenario, Having Diabetes, Deductible $300
SBC Scenario, Having Diabetes, Limit $0
SBC Scenario, Treatment of a Simple Fracture, Coinsurance $0
SBC Scenario, Treatment of a Simple Fracture, Copayment $300
SBC Scenario, Treatment of a Simple Fracture, Deductible $2,200
SBC Scenario, Treatment of a Simple Fracture, Limit $0
Service Area ID OHS011
Source Name SERFF
Plan ID 33931OH0030021
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 40.00%
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Group $10000 per group
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Family Per Person $5000 per person
Combined Medical and Drug EHB Deductible, In Network (Tier 1), Individual $5,000
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 $16000 per group
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Family Per Person $8000 per person
Maximum Out of Pocket for Medical and Drug EHB Benefits (Total), In Network (Tier 1), Individual $8,000
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 Silver Standard (No Referrals) Health Insurance Plan, 33931OH0030021

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

Frequently Asked Questions(FAQ) about UHC Silver Standard (No Referrals), 33931OH0030021 Health Insurance Plan, 33931OH0030021

  • Does UHC Silver Standard (No Referrals) Health Insurance Plan, 33931OH0030021 support Mail Ordering?

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

  • Does (33931OH0030021) Health Insurance Plan, Variant (33931OH0030021-01) have Out Of Country Coverage?

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

    Does (33931OH0030021) Health Insurance Plan, Variant (33931OH0030021-01) 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