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.

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 ApplicableNot Applicable 100.00% Cost share applies to both in-person and virtual services.
Specialist Visit
Covered
$80.00 Copay after deductible Not ApplicableNot 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 ApplicableNot Applicable 100.00%
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Surgery Physician/Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Hospice Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 deductibleNot 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 ApplicableNot Applicable 100.00%
Routine Eye Exam (Adult)
Urgent Care Centers or Facilities
Covered
$100.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Home Health Care Services
Covered
$80.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Emergency Room Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Emergency Transportation/Ambulance
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Inpatient Physician and Surgical Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Bariatric Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00% For surgical treatment of morbid obesity.
Cosmetic Surgery
Skilled Nursing Facility
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 deductibleNot Applicable 100.00% See plan documents for separate professional services cost shares.
Mental/Behavioral Health Outpatient Services
Covered
$40.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Mental/Behavioral Health Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Substance Abuse Disorder Outpatient Services
Covered
$40.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Substance Abuse Disorder Inpatient Services
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Generic Drugs
Covered
$3.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Preferred Brand Drugs
Covered
$200.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Non-Preferred Brand Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Specialty Drugs
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Outpatient Rehabilitation Services
Covered
$80.00 Copay after deductible Not ApplicableNot 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 ApplicableNot 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 ApplicableNot 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 deductibleNot 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 deductibleNot 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 deductibleNot 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 ApplicableNot Applicable 100.00%1.0 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 ApplicableNot Applicable 100.00%30.0 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
$80.00 Copay after deductible Not ApplicableNot 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 ApplicableNot Applicable 100.00%
X-rays and Diagnostic Imaging
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 deductibleNot 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 deductibleNot Applicable 100.00%
Dialysis
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Allergy Testing
Covered
$80.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Chemotherapy
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Radiation
Covered
Not Applicable 50.00% Coinsurance after deductibleNot Applicable 100.00%
Diabetes Education
Covered
$0.00 Copay after deductible Not ApplicableNot Applicable 100.00%
Prosthetic Devices
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 deductibleNot Applicable 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 ApplicableNot Applicable 100.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
Not Applicable 50.00% Coinsurance after deductibleNot 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 deductibleNot 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.

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

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