Bronze Simple- Standard
13877AZ0070051
Bronze
HMO
Bronze Simple- Standard is a Bronze HMO plan by Oscar Health Plan, Inc..
IMPORTANT: You are viewing the 2023 version of Bronze Simple- Standard 13877AZ0070051. You can enroll in this plan if you qualify for special enrollment until the end of 2023.
Locations
Bronze Simple- Standard is offered in the following counties.
Plan Overview
This is a plan overview for 2023 version of Bronze Simple- Standard 13877AZ0070051.
| Insurer: | Oscar Health Plan, Inc. |
| Network Type: | HMO |
| Metal Type: | Bronze |
| HSA Eligible?: | No |
| Plan ID: | 13877AZ0070051 |
Cost-Sharing Overview
Bronze Simple- Standard offers the following cost-sharing.
Cost-Sharing
Out-of-Network Cost-Sharing
Cost-Sharing Examples
Cost-Sharing
Cost-sharing for Bronze Simple- Standard includes your out-of-pocket maximum, your annual deductible, and coinsurance under this plan.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Pocket Maximum: | $9,100.00 | $9100 per person | $18200 per group |
| Deductible: | $9,100.00 | $9100 per person | $18200 per group |
| Coinsurance: | 0.00% | |
Out-of-Network Cost-Sharing
Some plans have different cost-sharing out-of-network. The out-of-network cost-sharing for Bronze Simple- Standard will be shown below if applicable.
| Cost Sharing Type | Individual | Family |
|---|---|---|
| Out-of-Network Maximum: | Not Applicable | per person not applicable | per group not applicable |
| Out-of-Network Deductible: | Not Applicable | 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: | $9,100.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $5,200.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| Limit: | $0.00 |
| Deductible: | $2,800.00 |
| Copayment: | $0.00 |
| Coinsurance: | $0.00 |
| 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- Standard?
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- Standard offers the following features and referral requirements.
| Wellness Program: | No |
| Disease Program: | Asthma, Heart Disease, Depression, Diabetes, High Blood Pressure & High Cholesterol, Low Back Pain, Pain Management, Pregnancy, Weight Loss Programs |
| 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- Standard 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- Standard 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 | No Charge after deductible | 100.00% | Virtual visits with an Oscar Care primary care provider are unlimited and always $0?even if you haven?t hit your deductible. Depending on your plan, many prescriptions and labs will also cost you $0, if they?re ordered by your Oscar Virtual Primary Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Primary Care provider under a Silver, Gold, or Platinum plan. |
| Specialist Visit Covered | No Charge after deductible | 100.00% | |
| Other Practitioner Office Visit (Nurse, Physician Assistant) Covered | No Charge after deductible | 100.00% | |
| Outpatient Facility Fee (e.g., Ambulatory Surgery Center) Covered | No Charge after deductible | 100.00% | |
| Outpatient Surgery Physician/Surgical Services Covered | No Charge after deductible | 100.00% | |
| Hospice Services Covered | No Charge after deductible | 100.00% | The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. |
| Routine Dental Services (Adult) | |||
| Infertility Treatment | |||
| Long-Term/Custodial Nursing Home Care | |||
| Private-Duty Nursing Covered | No Charge after deductible | 100.00% | Private hospital rooms and/or private duty nursing are only available during inpatient stays and determined to be medically appropriate by the Plan. Private duty nursing is available only in an inpatient setting when skilled nursing is not available from the facility. Custodial Nursing is not covered by the Plan. |
| Routine Eye Exam (Adult) | |||
| Urgent Care Centers or Facilities Covered | No Charge after deductible | 100.00% | |
| Home Health Care Services Covered | No Charge after deductible | 100.00% | 42 Visit(s) per Year 1. The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.; 2. The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.; 3. The patient must be homebound unless services are determined to be medically necessary by the Medical Management Organization.; 4. The home health agency delivering care must be certified within the state the care is received.; 5. The care that is being provided is not custodial care. A Home Health visit is considered to be up to four hours of services. |
| Emergency Room Services Covered | No Charge after deductible | No Charge after deductible | |
| Emergency Transportation/Ambulance Covered | No Charge after deductible | No Charge after deductible | |
| Inpatient Hospital Services (e.g., Hospital Stay) Covered | No Charge after deductible | 100.00% | |
| Inpatient Physician and Surgical Services Covered | No Charge after deductible | 100.00% | |
| Bariatric Surgery Covered | No Charge after deductible | 100.00% | 1. The patient must have a body-mass index (BMI) greather than equal to 35.; 2. Have at least one co-morbidity related to obesity.; 3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient’s medical record: Active participation within the last two years in one physician-supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of all of the following components:a. Weight; b. Current dietary program; c. Physical activity (e.g., exercise program); 4. In addition, the procedure must be performed at an approved Center of Excellence facility that is credentialed by your Health Network to perform bariatric surgery.; 5. The member must be 18 years or older, or have reached full expected skeletal growth. |
| Cosmetic Surgery | |||
| Skilled Nursing Facility Covered | No Charge after deductible | 100.00% | 90 Days per Year |
| Prenatal and Postnatal Care Covered | $0.00 | 100.00% | |
| Delivery and All Inpatient Services for Maternity Care Covered | No Charge after deductible | 100.00% | Newborn benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship. |
| Mental/Behavioral Health Outpatient Services Covered | No Charge after deductible | 100.00% | |
| Mental/Behavioral Health Inpatient Services Covered | No Charge after deductible | 100.00% | |
| Substance Abuse Disorder Outpatient Services Covered | No Charge after deductible | 100.00% | |
| Substance Abuse Disorder Inpatient Services Covered | No Charge after deductible | 100.00% | |
| Generic Drugs Covered | No Charge after deductible | 100.00% | |
| Preferred Brand Drugs Covered | No Charge after deductible | 100.00% | |
| Non-Preferred Brand Drugs Covered | No Charge after deductible | 100.00% | |
| Specialty Drugs Covered | No Charge after deductible | 100.00% | |
| Outpatient Rehabilitation Services Covered | No Charge after deductible | 100.00% | 60 Visit(s) per Year Short-term rehabilitative therapy includes services in an outpatient facility or physician’s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Visit limit is for all therapy types combined. |
| Habilitation Services Covered | No Charge after deductible | 100.00% | Supplementing with the federal definition of habilitative services: Health care services that help a person keep, learn, or improve skills and functioning for daily living. Examples include therapy for a child who is not walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings. |
| Chiropractic Care Covered | No Charge after deductible | 100.00% | 20 Visit(s) per Year HMOs may limit chiropractic visits to 20; PPOs must cover medically necessary chiropractic visits. |
| Durable Medical Equipment Covered | No Charge after deductible | 100.00% | |
| Hearing Aids Covered | No Charge after deductible | 100.00% | 1 Item(s) per Benefit Period Hearing aid devices limited to one per ear, per Plan Year when determined to be medically necessary by the Medical Management Organization. |
| Imaging (CT/PET Scans, MRIs) Covered | No Charge after deductible | 100.00% | |
| Preventive Care/Screening/Immunization Covered | $0.00 | 100.00% | 1 Exam(s) per Year Well Woman and Well Man examinations are limited to 1 visit per year. |
| Routine Foot Care | |||
| Acupuncture | |||
| Weight Loss Programs | |||
| Routine Eye Exam for Children Covered | No Charge after deductible | 100.00% | |
| Eye Glasses for Children Covered | No Charge after deductible | 100.00% | |
| Dental Check-Up for Children Not Covered | |||
| Rehabilitative Speech Therapy Covered | No Charge after deductible | 100.00% | 60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST). |
| Rehabilitative Occupational and Rehabilitative Physical Therapy Covered | No Charge after deductible | 100.00% | 60 Visit(s) per Year Visit limit is for all therapy types combined (PT, OT, ST). |
| Well Baby Visits and Care Covered | $0.00 | 100.00% | Well Child visits and immunizations are covered through 47 months as recommended by the American Academy of Pediatrics. |
| Laboratory Outpatient and Professional Services Covered | No Charge after deductible | 100.00% | |
| X-rays and Diagnostic Imaging Covered | No Charge after deductible | 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 | No Charge after deductible | 100.00% | Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor. Organ transplant services include the recipient’s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:1. Allogeneic bone marrow/stem cell;2. Autologous bone marrow/stem cell;3. Cornea;4. Heart;5. Heart/lung;6. Kidney;7. Kidney/pancreas;8. Liver;9. Lung;10. Pancreas;11. Small bowel/liver; or 12. Kidney/liver. Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary. |
| Accidental Dental Covered | No Charge after deductible | 100.00% | Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an accidental injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident. |
| Dialysis Covered | No Charge after deductible | 100.00% | |
| Allergy Testing Covered | No Charge after deductible | 100.00% | |
| Chemotherapy Covered | No Charge after deductible | 100.00% | |
| Radiation Covered | No Charge after deductible | 100.00% | |
| Diabetes Education Covered | $0.00 | 100.00% | |
| Prosthetic Devices Covered | No Charge after deductible | 100.00% | The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury, congenital defect, or alopecia as a result of chemotherapy, radiation therapy, and second or third degree burns. External prosthetic appliances shall include artificial arms and legs, wigs, hair pieces and terminal devices such as a hand or hook. Wigs and hair pieces are limited to one per Plan Year and $150 maximum. Members must provide a valid prescription verifying diagnosis of alopecia as a result of chemotherapy, radiation therapy, second or third degree burns with a submitted claim for coverage. All other diagnosis are excluded. Replacement of artificial arms and legs and terminal devices are covered only if necessitated by normal anatomical growth or as a result of wear and tear. |
| Infusion Therapy Covered | No Charge after deductible | 100.00% | Infusion/IV Therapy in an Outpatient setting including, but not limited to: Inflixima/b (Remicade), Alefacept (Amevive), and Etanercept (Enbrel). |
| Treatment for Temporomandibular Joint Disorders Covered | No Charge after deductible | 100.00% | Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of: 1. An accident; 2. Trauma; 3. A congenital defect; 4. A developmental defect; or 5. A pathology. |
| Nutritional Counseling Covered | No Charge after deductible | 100.00% | Covered when dietary adjustment has a therapeutic role of a diagnosed chronic disease/condition, including but not limited to:1. Morbid obesity 2. Diabetes3. Cardiovascular disease 4. Hypertension 5. Kidney disease 6. Eating disorders 7. Gastrointestinal disorders 8. Food allergies 9. Hyperlipidemia |
| Reconstructive Surgery Covered | No Charge after deductible | 100.00% | Following a mastectomy, the following services and supplies are covered:1. Surgical services for reconstruction of the breast on which the mastectomy was performed;2. Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;3. Post-operative breast prostheses; and 4. Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs.During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered. Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children. |
| Gender Affirming Care Covered | No Charge after deductible | 100.00% |
Free Preventive Services
There is no copayment or coinsurance for any of the following Bronze Simple- Standard 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- Standard 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- Standard?
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