Bronze Simple HSA
69803NC0010014
Expanded Bronze
HMO
Bronze Simple HSA is an Expanded Bronze HMO plan by Oscar Health Plan of North Carolina, Inc.
IMPORTANT: You are viewing the 2024 version of Bronze Simple HSA 69803NC0010014. You can enroll in this plan during open enrollment 2024, which starts November 1st and ends January 15th, 2023, in most states.
Locations
Bronze Simple HSA is offered in the following counties.
Plan Overview
This is a plan overview for 2024 version of Bronze Simple HSA 69803NC0010014.
| Insurer: | Oscar Health Plan of North Carolina, Inc |
| Network Type: | HMO |
| Metal Type: | Expanded Bronze |
| HSA Eligible?: | Yes |
| Plan ID: | 69803NC0010014 |
Cost-Sharing Overview
Bronze Simple HSA offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Bronze Simple HSA includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $7450 per person | $14900 per group |
| Deductible: | $5000 per person | $10000 per group |
| Coinsurance: | 50.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Bronze Simple HSA will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | per person not applicable | per group not applicable |
Cost-Sharing Examples
The cost-sharing for the sample Summary of Benefits & Coverage (SBC) scenarios of having a baby, having diabetes, and having a simple fracture.
| Deductible: | $5,000.00 |
| Copayment: | $0.00 |
| Coinsurance: | $2,400.00 |
| Limit: | $0.00 |
| Deductible: | $5,000.00 |
| Copayment: | $200.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $2,500.00 |
| Copayment: | $0.00 |
| Coinsurance: | $100.00 |
| Limit: | $0.00 |
Notes:
- Some plans have separate cost-sharing for medical and drugs, while other plans offer combined cost-sharing. The cost-sharing amounts above are combined medical and drug costs unless otherwise noted.
- You are viewing the standard version of this plan. Your costs may be lower depending on your income. Use the “get a quote” button below to see your estimated premium and out-of-pocket costs after assistance.
Ready to sign up for Bronze Simple HSA?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904
Plan Features
Bronze Simple HSA offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Pregnancy |
| Notice Pregnancy: | No |
| Referral Specialist: | No |
| Specialist Requiring Referral: | |
| Plan Exclusions: | |
| Child Only Option?: | Allows Adult and Child-Only |
Network Details
The following network details will help you understand what Bronze Simple HSA covers when you are out of the service area or out of the country.
| 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 |
| National Network: | No |
Additional Benefits and Cost-Sharing
Bronze Simple HSA includes the following benefits at the cost sharing rates listed below.
| Service | In-Network Copay / Coinsurance | Out-of-Network Copay / Coinsurance | Limits and Explanation |
|---|---|---|---|
| Primary Care Visit to Treat an Injury or Illness Covered | $40.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Cost share applies to both in-person and virtual services. |
| Specialist Visit Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Cost share applies to both in-person and virtual services. |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | $40.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Hospice Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Benefits for Hospice services for care of a terminally ill Member with a life expectancy of six months or less. |
| Routine Dental Services (Adult) | |||
| Infertility Treatment Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 3.0 Treatment(s) per Lifetime Infertility Services- Benefits are provided for certain services related to the diagnosis, treatment and correction of any underlying causes of infertility for all members. Benefits are limited to three medical ovulation induction cycles per lifetime per member. Prescription Drug Benefits- Certain prescription drugs related to treatment of infertility. Infertility drugs are limited to benefit lifetime maximums per member. |
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Routine Eye Exam (Adult) | |||
| Urgent Care Centers or Facilities Covered | $100.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Home Health Care Services Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Emergency Room Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Emergency Transportation/Ambulance Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 50.00% Coinsurance after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Inpatient Physician and Surgical Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Bariatric Surgery Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | For surgical treatment of morbid obesity. |
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 60.0 Days per Benefit Period |
| Prenatal and Postnatal Care Covered | Not Applicable 0.00% | Not Applicable 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | See plan documents for separate professional services cost shares. |
| Mental/Behavioral Health Outpatient Services Covered | $40.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | $40.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Generic Drugs Covered | $3.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Preferred Brand Drugs Covered | $200.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Non-Preferred Brand Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Specialty Drugs Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Outpatient Rehabilitation Services Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
| Habilitation Services Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
| Chiropractic Care Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic). |
| Durable Medical Equipment Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime. |
| Hearing Aids Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids, once every 36 months. |
| Imaging (CT/PET Scans, MRIs) Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Preventive Care/Screening/Immunization Covered | Not Applicable 0.00% | Not Applicable 100.00% | All preventive care that is not state mandated is not covered OON. |
| Routine Foot Care | |||
| Acupuncture | |||
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | $0.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 1.0 Exam(s) per Benefit Period |
| Eye Glasses for Children Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | 1.0 Item(s) per Benefit Period |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | 30.0 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services. |
| Well Baby Visits and Care Covered | Not Applicable 0.00% | Not Applicable 100.00% | |
| Laboratory Outpatient and Professional Services Covered | $10.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| X-rays and Diagnostic Imaging Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Basic Dental Care – Child Not Covered | |||
| Orthodontia – Child Not Covered | |||
| Major Dental Care – Child Not Covered | |||
| Basic Dental Care – Adult | |||
| Orthodontia – Adult | |||
| Major Dental Care – Adult | |||
| Abortion for Which Public Funding is Prohibited | |||
| Transplant Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Benefits are provided for reasonable and necessary services related to the search for a donor up to a maximum of $10,000 per transplant; Both the recipient and the donor are entitled to benefits of this coverage when the recipient is a MEMBER. Benefits provided to the donor will be charged against the recipient’s coverage. |
| Accidental Dental Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Dialysis Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Allergy Testing Covered | $80.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Chemotherapy Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Radiation Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Diabetes Education Covered | $0.00 Copay after deductible Not Applicable | Not Applicable 100.00% | |
| Prosthetic Devices Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Prosthetic appliance must replace all or part of a body part or its function. Therapeutic contact lenses may be covered when used as a corneal bandage for a medical condition; benefits include a one-time replacement of eyeglass or contact lenses due to a prescription change following cataract surgery. |
| Infusion Therapy Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | |
| Treatment for Temporomandibular Joint Disorders Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Therapeutic benefits for TMJ disease include splinting and use of intra-oral PROSTHETIC APPLIANCES to reposition the bones. Surgical benefits for TMJ disease are limited to SURGERY performed on the temporomandibular joint. If TMJ is caused by malocclusion, benefits are provided for surgical correction of malocclusion when surgical management of the TMJ is MEDICALLY NECESSARY. |
| Nutritional Counseling Covered | $40.00 Copay after deductible Not Applicable | Not Applicable 100.00% | Nutritional counseling visits are separate from the obesity-related office visits. |
| Reconstructive Surgery Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% | Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy. |
| Gender Affirming Care Covered | Not Applicable 50.00% Coinsurance after deductible | Not Applicable 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following Bronze Simple HSA preventive services. This is true even if you haven’t met your yearly deductible.
Please note, these services are free only when delivered by a doctor or other provider in your plan’s network.
Preventive Care Benefits for All Adults
Preventive Care Benefits for Women
Preventive Care Benefits for Children
Preventive Care Benefits for All Adults
Preventive care benefits for adults
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease and colorectal cancer for adults 50 to 59 years with a high cardiovascular risk
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults 45 to 75
- Depression screening
- Diabetes (Type 2) screening for adults 40 to 70 years who are overweight or obese
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults age 18 to 79 years
- HIV screening for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
- Immunizations for adults — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria
- Flu (influenza)
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Measles
- Meningococcal
- Mumps
- Whooping Cough (Pertussis)
- Pneumococcal
- Rubella
- Shingles
- Tetanus
- Lung cancer screening for adults 50 to 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Statin preventive medication for adults 40 to 75 at high risk
- Syphilis screening for adults at higher risk
- Tobacco use screening for all adults and cessation interventions for tobacco users
- Tuberculosis screening for certain adults without symptoms at high risk
Preventive Care Benefits for Women
Services for pregnant women or women who may become pregnant
- Breastfeeding support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 weeks pregnant (or later) and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Maternal depression screening for mothers at well-baby visits
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Bone density screening for all women over age 65 or women age 64 and younger that have gone through menopause
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings
- Every 2 years for women 50 and over
- As recommended by a provider for women 40 to 49 or women at higher risk for breast cancer
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening
- Pap test (also called a Pap smear) for women age 21 to 65
- Chlamydia infection screening for younger women and other women at higher risk
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for everyone age 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Sexually transmitted infections counseling for sexually active women
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for all women
Preventive Care Benefits for Children
Coverage for children’s preventive health services
- Alcohol, tobacco, and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children: Age 0 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children: Age 0 to 17
- Blood screening for newborns
- Depression screening for adolescents beginning routinely at age 12
- Developmental screening for children under age 3
- Dyslipidemia screening for all children once between 9 and 11 years and once between 17 and 21 years, and for children at higher risk of lipid disorders
- Fluoride supplements for children without fluoride in their water source
- Fluoride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns; and regular screenings for children and adolescents as recommended by their provider
- Height, weight and body mass index (BMI) measurements taken regularly for all children
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at higher risk
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
Immunizations for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Chickenpox (Varicella)
- Diphtheria, tetanus, and pertussis (DTaP)
- Haemophilus influenza type b
- Hepatitis A
- Hepatitis B
- Human Papillomavirus (HPV)
- Inactivated Poliovirus
- Influenza (flu shot)
- Measles
- Meningococcal
- Mumps
- Pneumococcal
- Rubella
- Rotavirus
Lead screening for children at risk of exposure
Obesity screening and counseling
- Oral health risk assessment for young children from 6 months to 6 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis: Age 0 -17
- Vision screening for all children
- Well-baby and well-child visits
Additional Resources
Below are additional resources for Bronze Simple HSA including the Summary of Benefits & Coverage (SBC), plan brochure, formulary link, and a link to the website to pay your monthly premium after you enroll.
| Summary of Benefits: | Summary of Benefits Link |
| Plan Brochure: | Plan Brochure Link |
| Formulary: | Formulary Link |
| Premium Payment Website: | Premium Payment Link |
Ready to sign up for Bronze Simple HSA?
Click or call to enroll online, get a quote, or find out if you qualify for assistance.
Get Help from a licensed agent. 1-877-668-0904