Bronze Simple- Standard

69803NC0010051
Bronze
HMO

Bronze Simple- Standard is a Bronze HMO plan by Oscar Health Plan of North Carolina, Inc..

IMPORTANT: You are viewing the 2023 version of Bronze Simple- Standard 69803NC0010051. 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 69803NC0010051.
Insurer: Oscar Health Plan of North Carolina, Inc.
Network Type: HMO
Metal Type: Bronze
HSA Eligible?: No
Plan ID: 69803NC0010051

Cost-Sharing Overview

Bronze Simple- Standard 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- 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 urgent 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 Urgent Care team.* Please refer to your plan documents for more information. *For these savings to apply, they must be prescribed by your Oscar Virtual Urgent 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% 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
No Charge after deductible 100.00%3 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. The lifetime maximums are described in BCBSNC medical policies, which are guides considered by BCBSNC when making coverage determinations.
Long-Term/Custodial Nursing Home Care
Private-Duty Nursing
Covered
No Charge after deductible 100.00%
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%
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% For surgical treatment of morbid obesity.
Cosmetic Surgery
Skilled Nursing Facility
Covered
No Charge after deductible 100.00%60 Days per Benefit Period
Prenatal and Postnatal Care
Covered
$0.00 100.00%
Delivery and All Inpatient Services for Maternity Care
Covered
No Charge after deductible 100.00%
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%30 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Habilitation Services
Covered
No Charge after deductible 100.00%30 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Chiropractic Care
Covered
No Charge after deductible 100.00%30 Visit(s) per Benefit Period 30 visit limits for PT and OT combined (including chiropractic).
Durable Medical Equipment
Covered
No Charge after deductible 100.00% Orthotic devices for correction of POSITIONAL PLAGIOCEPHALY are limited to 1 device per lifetime.
Hearing Aids
Covered
No Charge after deductible 100.00%1 Item(s) per 3 Years One hearing aid per hearing impaired ear, and replacement hearing aids for members under the age of 22. Once every 36 months.
Imaging (CT/PET Scans, MRIs)
Covered
No Charge after deductible 100.00%
Preventive Care/Screening/Immunization
Covered
$0.00 100.00% 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
No Charge after deductible 100.00%1 Exam(s) per Benefit Period
Eye Glasses for Children
Covered
No Charge after deductible 100.00%1 Item(s) per Benefit Period
Dental Check-Up for Children
Not Covered
2 Visit(s) per Benefit Period
Rehabilitative Speech Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Benefit Period
Rehabilitative Occupational and Rehabilitative Physical Therapy
Covered
No Charge after deductible 100.00%30 Visit(s) per Benefit Period Combined 30 visit limit for occupational and physical therapies and chiropractic services.
Well Baby Visits and Care
Covered
$0.00 100.00%
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% 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
No Charge after deductible 100.00%
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% 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
No Charge after deductible 100.00%
Treatment for Temporomandibular Joint Disorders
Covered
No Charge after deductible 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
No Charge after deductible 100.00% Nutritional counseling visits are separate from the obesity-related office visits.
Reconstructive Surgery
Covered
No Charge after deductible 100.00% Benefits include coverage for congenital defects of newborn, adopted, and foster children; reconstruction following a mastectomy.
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.

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

Table of Contents