All You Need to Know About Oscar Plans for 2023 in Texas
When shopping for a health insurance plan in Texas, you want to find an affordable company that will meet your family’s needs. Your choice of companies will depend on your situation. Are you healthy, or will you need coverage from day one? All your options can be quite confusing. We at Cover Mile are here to assist you with understanding what Oscar Health Insurance has to offer and if they are the best fit for you and your family.
Health Insurance Terms to Understand
Before we begin, let’s provide a few brief definitions behind some of the terms you will see frequently but may not completely understand. This will better aid you in selecting the best health coverage that fits your situation.
Deductible – A deductible is the amount you will pay out of pocket before your insurance kicks in. Oscar has deductibles from $0 up to $9100, depending on the plan you choose. Deductibles are based on the calendar year and start over each year. They also determine how much you will pay overall. The higher your deductible, the lower your premium; the lower your deductible, the higher your premium will be. A deductible is broken down into two parts:
Individual: This is the per-person deductible.
Family: This is the deductible for the entire family.
You will see this reflected on your Summary of Benefits, often in fraction form. For instance, $750 Individual/$2250 Family. Each family member will have their own $750 out-of-pocket expense to reach. Read more about deductibles through the link above.
Co-insurance – Co-insurance is where the insurance kicks in. It is cost sharing between you and the insurance company, usually based on a percentage. They are reflected, such as 70/30. The 70 is the amount the insurance pays toward your medical fees, and the 30 percent is what you will pay. Co-insurances refresh each year.
Out-of-Pocket Max – Insurance policies have an out-of-pocket max. These help those with large families, those who visit the doctor regularly, and with medical conditions. When you meet your deductible, pay through your co-insurance, and reach the out-of-pocket amount specified in your policy, your insurance begins to pay 100 percent of medical expenses for that individual. This continues until the calendar year rolls over. This, like your deductible, applies to both an individual and family.
Primary Care Physician – Your Primary Care Physician (PCP) is the main doctor you visit for medical care. With Oscar, an EPO, you can see any doctor you wish, and you do not need their recommendation to see a Specialist as you would with an HMO. However, you must remain within the network of EPO doctors and facilities, or you will not have coverage. This rule does not apply if you are in an emergency.
Copay – Copays are the amount you pay the doctor or facility for your visit. This can be a flat dollar amount or a percentage. It varies by plan. Remember this will be for the office visit alone, not the treatment you receive. However, some plan’s treatments may be included in an office visit, like a well checkup; see your plan for details.
Now that we have reviewed the basics of health insurance, let’s take you through the plans Oscar offers its subscribers.
Oscar and the Affordable Care Act
Oscar sells plans that are part of the Affordable Care Act. They offer plans on all three tiers: Bronze, Silver, and Gold. Although their offering is limited on the upper tier levels, offering only one Gold plan. However, they offer three unique plans targeted to those with Diabetes.
When you shop Oscar and see their price charts, you will notice two different brackets. One for Oscar Texas and one for Oscar Houston. This is due to the expanded markets that Houston has: Oscar Choice and Oscar Select. This gives those living in the area a more extensive network of facilities and doctors catered to the area residents live in that best suit their families. There does not appear to be a benefit difference between the two, just the network available.
Oscar Bronze
Oscar Bronze has eight plans; all are available on the Marketplace. Each has a different deductible, out-of-pocket max, and copay to see doctors and specialists. The Bronze level often has the highest deductibles but will have the lowest premiums of the medal levels. Oscar has the Bronze Elite, a zero-percent plan, meaning there is no deductible to meet, and your co-insurance automatically kicks in until you reach your out-of-pocket max.
| Bronze | Bronze Simple | Bronze Classic | Bronze Elite $0 Ded+PCP Saver |
| Deducible | $8500/$17,000 | $7750/$15,500 | $0/$0 |
| Co-insurance | 50% | 50% | 0% |
| Out-of-Pocket Max | $9100/$18,200 | $9100/$18,200 | $9100/$18,200 |
| Primary Care Visit | 50% after deductible | 50% after copay | $40 |
| Virtual Primary Care | $0 | $0 | $0 |
| Specialist Visit | 50% after deductible | $100 copay | $125 |
| Virtual Specialist | $0 | $0 | $0 |
| Emergency Room | 50% after deductible | 50% after deductible | $1500 |
| Urgent Care | $75 copay | $75 copay | $75 |
| Inpatient Hospital | 50% after deductible | 50% after deductible | $3000 |
| Outpatient Hospital | 50% after deductible | 50% after deductible | $1200 |
| Prescription (Pharmacy) | $3/$30/50% after deductible* | $3/$30/50% after deductible* | $3/$30/$50 after deductible/50% a.d. |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Oscar Silver
Oscar Silver has six plans; all are available on both the Marketplace and the Oscar health insurance website. Silver plans tend to be the target for the Affordable Care Act due to their pricing, and they tend to help those who qualify for cost-sharing reductions and premium tax credits.
| Silver | Silver Classic | Silver Simple – PCP Saver | Silver Elite – $0 Deductible |
| Deducible | $5400/$10,800 | $5500/$11,000 | $0/$0 |
| Co-insurance | 30% | 30% | N/A |
| Out-of-Pocket Max | $8700$17,400 | $8700/$17,400 | $9100/$18,200 |
| Primary Care Visit | $35 copay | $30 copay | $60 |
| Virtual Primary Care | $0 copay | $0 Copay | $0 copay |
| Specialist Visit | $95 copay | $60 copay | $80 copay |
| Virtual Specialist Visit | $0 copay | $0 copay | $0 copay |
| Emergency Room | $750 after deductible | 25% after deductible | 50% |
| Urgent Care | $80 copay | $45 copay | $60 copay |
| Inpatient Hospital | 50% after deductible | 25% after deductible | 50% |
| Outpatient Hospital | 50% after deductible | 25% after deductible | 50% |
| Prescription (Pharmacy) | $3/$25/$75/$50% after deductible* | $15/$15/$30$60/ $250* | $3/$30/$200/50%/50% |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Oscar has 18 Silver plans designed for the Cost Sharing Reduction program. These are accessible when one qualifies for premium tax credits through the Marketplace website.
| Silver CSR | Silver Classic CSR 150 | Silver Simple – PCP Saver CSR 200 | Silver Classic CSR 250 |
| Deducible | $0/$0 | $600/$1200 | $4400/$8600 |
| Co-insurance | 30% | 30% | 30% |
| Out-of-Pocket Max | $1550/$3100 | $3000/$6000 | $7000/$14,000 |
| Primary Care Visit | $0 copay | $10 copay | $35 |
| Virtual Primary Care | $0 copay | $0 Copay | $0 |
| Specialist Visit | $5 copay | $40 copay | $80 |
| Virtual Specialist Visit | $0 copay | $0 copay | $0 |
| Emergency Room | $500 | 40% after deductible | $750 after deductible |
| Urgent Care | $15 copay | $50 copay | $80 |
| Inpatient Hospital | 20% | 40% after deductible | 40% after deductible |
| Outpatient Hospital | 20% | 40% after deductible | 40% after deductible |
| Prescription (Pharmacy) | $0/$5/$15/$50% after deductible* | $3/$10/$40/40% after deductible* | $3/$25/$75/50% after deductible* |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Simple Silver for Diabetes
Oscar also has three plans under the CSR program designed for those with Diabetes. They are similar to the plans above but offer special services such as $0 diabetic labs, $0 foot and eye exams, and insulin for no more than $100 per month.
Oscar Gold
Oscar is limited to only one Gold plan. The Oscar Gold Standard is typical of Gold plans; it has a low deductible and provides the best coverage of the plans Oscar offers. It has a low copay and deductible and will have a lower out-of-pocket cost than the other plans. Gold plans come with a higher price tag. They are best suited for those with chronic medical conditions requiring frequent doctor visits or those who desire advanced medical care.
| Gold | Gold Classic Standard |
| Deducible (Individual/Family) | $2000/$4000 |
| Co-insurance | 20% |
| Out-of-Pocket Max (Individual/Family) | $8700/$17,400 |
| Primary Care Visit | $30 |
| PCP Virtual Visits | $0 |
| Specialist Visit | $60 |
| Emergency Room | 25% after deductible |
| Urgent Care | $45 |
| Virtual Urgent Care | $0 |
| Inpatient Hospital | 25% after deductible |
| Outpatient Hospital | 25% after deductible |
| Prescription (Pharmacy) | $15/$15/$30/$60/$250* |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Oscar Dental and Vision:
It does not appear that Oscar offers Dental or Vision plans as stand-alone policies or add-ons. Although part of the Affordable Care Act, they must offer this benefit to children as part of the 10 Essential Benefits.
Finding a Doctor or Facility in Your Network
As an EPO, you must remain within your network of providers. However, Oscar does assist with a great search engine that enables you to find a doctor by specialty, facility, or network. This will keep you from wondering if you are straying from your local area and in danger of not being covered.
Oscar allows you to search for doctors and facilities near you and read about prescriptions you may be taking.
Benefit Notices:
Keep in mind that the above is a summary of highlights only.
–The benefits above represent what a member would pay. When a non-participating provider is used, benefits are reduced.
–Oscar has negotiated rates with in-network providers. Member pays rate with in-network providers until reaching their deductible.
–Member pays co-insurance percentage until deductible and out-of-pocket max is reached. The plan will pay 100% after that.
–Prescription benefit levels are: Generics Preferred, Generics Non-Preferred, Brand Preferred, Brand Non-Preferred, and Specialty
–Oscar Care in-person visits in conjunction with your virtual visit may have a copayment.
–Due to medical licensing laws, you must be in your home state at the time of your virtual visit.
Prescription Coverage with Oscar
All Oscar plan members receive Prescription coverage. Each plan has varied coverage and tiers. Each has these need-to-knows.
- Know Your Cost Estimate – You can view the estimated cost of your prescription before you purchase it. You will see the amount before your deductible, after you’ve met it, and after your out-of-pocket max has been reached.
- Prior Authorization – In most cases, you will require prior approval to fill prescriptions from Oscar. They may approve a more cost-effective drug instead of a suggested prescription.
- $3 Prescriptions – Depending on your plan and the prescription you are taking; you may receive your medication for as low as $3 per month.
Oscar can help you find a pharmacy in your area through its website, including prescription mail delivery.
At Cover Mile, we desire to assist you in finding the health insurance in Texas that best suits you and your family. We will take the time to talk you through each plan, help you understand each Oscar Insurance plan, and help you sign up for Affordable Care Act insurance. Contact us today.
Frequently Asked Questions
FAQs
Is Oscar Health Insurance Any Good?
Oscar has beneficial plans for those seeking affordable health coverage, especially those who qualify for premium tax credits. However, their lack of adult dental and vision benefits does leave them wanting.
Is Oscar Health Insurance Going Out of Business?
If you read the financial news in your research for health insurance, you may have read about the exit of Oscar from Arkansas and Colorado. According to their CEO, those markets were small and non-profitable. Oscar is rapidly growing, and you are in the big state of Texas, no worries here.
Is Oscar Insurance Part of Obamacare?
Yes. As you read earlier, the CSR plans are all connected with Obamacare and provide the benefits of a premium tax credit for lower-income health insurance seekers in Texas.
How to Cancel Oscar Health Insurance
To cancel your health insurance plan with Oscar Texas, it would depend on how you purchased it. If it was through the Exchange, visit the Heathcare.gov website and follow the instructions. If your purchase was with a broker, you can cancel with them directly, or you can contact Cover Mile, and we can walk you through the process. If you purchased it online, contact them at the number provided on their website for assistance.
Does Oscar Insurance Have Any Providers in Texas?
You can search for doctors, pharmacies, hospitals, and other medical providers in Texas on their website. If you live in the Houston area, they offer dual networks, Oscar Choice and Oscar Select to provide more options for members.
