All You Need to Know About Oscar Health Plans for 2024
When shopping for Texas health insurance for you and your family, you want to find an affordable company that will meet your needs. Your choice will depend on your situation. Are you healthy, or will you need coverage from day one? All the options set before you can be quite confusing. We at CoverMile 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 Insurance has deductibles ranging from $0 up to $9450, depending on your plan selection. Deductibles are based on the calendar year and refresh 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 in your Summary of Benefits, often in fraction form. For instance, $750 Individual/$1500 Family. On most policies, the family deductible is the individual deductible doubled. Each family member will have their own $750 out-of-pocket expense to reach. Read more about deductibles through the link above.
Coinsurance – Coinsurance is where the insurance begins to pay. It is cost sharing between you and the insurance company, usually based on a percentage. With Oscar Insurance, it will be listed as “50% coinsurance” or just “50%”, whatever your policy’s coverage level is. This is the portion you will pay. It refreshes each year. Understand that on a Summary of Benefits, when you see a percentage, it means after your deductible is met unless otherwise specified.
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 individuals with medical conditions. When you meet your deductible, pay through your coinsurance portion, and reach the out-of-pocket max specified in your policy, your insurance begins to pay 100 percent of medical expenses. 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 EPO network of doctors and facilities, or you will not have coverage. The exception to this rule is if you experience an emergency. However, it is best to contact your insurance company to inform them of your situation.
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 insurer and 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 or immunizations; 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 Insurance sells plans that are part of the Affordable Care Act. They offer plans on all three tiers: Bronze, Silver, and Gold. They also offer a host of plans designated for cost-saving reductions on the Silver metal level. We have included a few below.
Dual Network Options
When shopping Oscar insurance, you may notice two different price charts. This is due to the expanded markets that Houston has: Oscar Choice and Oscar Select. Houston area residents have the option between these two networks.
Oscar Choice Network
The Choice network is available in Harris, Fort Bend, Montgomery, Galveston, and Brazoria counties. It uses select hospitals in the area to provide medical care to policyholders.
Oscar Select Network
The Select network is smaller than Choice but offers cost-effective medical care without sacrificing quality. This network is available in Harris, Fort Bend, Montgomery, Galveston, and Brazoria counties.
There does not appear to be a benefit difference between the two coverages or costs, just the network available. However, some plans may not be offered on the Choice network that are offered on the Select.
Plan Suite Options
Also, as you are reviewing Oscar insurance in Texas, you will see they have different plans. They call them ‘suites’ for you to choose from: Simple, Classic, and Elite. They break down as follows:
Simple: least expensive, but with a high coinsurance.
Classic: mid-range premium. You will see your Summary of Benefits with a mix of coinsurance and copays.
Elite: Mostly copays and less coinsurance with 0% medical deductibles.
Oscar Bronze
Oscar offers five plans on their Bronze tier. Three of those are offered on the Choice network. Each plan has a different deductible, out-of-pocket max, and copay to see doctors and specialists. The Bronze tier has the highest deductibles but will usually have the lowest premiums. Oscar has the Bronze Elite, a zero-percent plan, meaning there is no deductible to meet, and your coinsurance automatically kicks in until you reach your out-of-pocket max.
| Bronze | Bronze Classic 4700 | Bronze Classic Standard | Bronze Elite +PCP Saver |
| Deducible | $4700/$9,400 | $7500/$15,000 | $0/$0 |
| Coinsurance | 50% | 50% | 50% |
| Out-of-Pocket Max | $9100/$18,200 | $9,450/$18,800 | $9450/$18,900 |
| Primary Care Visit | $70 | $50 | $40 |
| Virtual Primary Care | $70 | $50 | $0 |
| Specialist Visit | $125 copay | $100 | $70 |
| Virtual Urgent Care | $0 | $0 | $0 |
| Emergency Room | 50% after deductible | 50% after deductible | $2000 |
| Urgent Care | $125 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/$100/50% after deductible* | $3/$30/$100 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 most popular for Affordable Care Act shoppers due to their pricing, and they assist those who qualify for cost-sharing reductions and tax credits.
| Silver | Silver Classic | Silver Simple PCP Saver | Silver Elite Saver Plus |
| Deducible | $5400/$10,800 | $5750/$11,500 | $0/$0 |
| Coinsurance | 50% | 40% | 50% |
| Out-of-Pocket Max | $8900/$17,800 | $8900/$17,800 | $9100/$18,200 |
| Primary Care Visit | $35 copay | $20 copay | $60 |
| Virtual Primary Care | $0 copay | $0 Copay | $0 copay |
| Specialist Visit | $95 copay | $80 copay | $100 copay |
| Virtual Urgent Care | $0 copay | $0 copay | $0 copay |
| Emergency Room | $750 after deductible | 40% after deductible | 50% |
| Urgent Care | $100 copay | $75 copay | $50 copay |
| Inpatient Hospital | 50% after deductible | 40% after deductible | 50% |
| Outpatient Hospital | 50% after deductible | 40% after deductible | 50% |
| Prescription (Pharmacy) | $3/$25/$75/$50% after deductible* | $3/$25/$75/30% after deductible* | $3/$30/$125/ 50%/50% |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Oscar has 15 Silver tier plans designed for Cost Sharing Reductions. One can receive added savings when one qualifies for premium tax credits through the Affordable Care Act.
| Silver CSR | Silver Classic CSR 150 | Silver Simple – PCP Saver CSR 200 | Silver Classic CSR 250 |
| Deducible | $0/$0 | $600/$1200 | $4750/$9500 |
| Coinsurance | 20% | 40% | 40% |
| Out-of-Pocket Max | $1550/$3100 | $3000/$6000 | $7200/$14,400 |
| Primary Care Visit | $5 copay | $10 copay | $20 |
| Virtual Primary Care | $0 copay | $0 Copay | $0 |
| Specialist Visit | $10 copay | $40 copay | $80 |
| Virtual Urgent Care | $0 copay | $0 copay | $0 |
| Emergency Room | 20% | 40% after deductible | 40% after deductible |
| Urgent Care | $30 copay | $50 copay | $75 |
| Inpatient Hospital | 20% | 40% after deductible | 40% after deductible |
| Outpatient Hospital | 20% | 40% after deductible | 40% after deductible |
| Prescription (Pharmacy) | $0/$5/$30/$20% after deductible* | $3/$10/$40/40% after deductible* | $3/$20/$80/40% after deductible* |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Enhanced Diabetes Care
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 PCP visits, diabetic labs, foot and eye exams, and insulin for no more than $100 per month.
BreatheEasy Plan
This is a plan designed for those who have issues with COPD and asthma. These members will have $0 pulmonologist and PCP visits, pulmonology rehab, and oxygen. For RX services, they will have $0 tier 1 medications, nicotine replacement, and behavioral services.
HolaOscar Program
To address the ever-expanding Hispanic member base, Oscar has developed Spanish cultural care with providers who speak the language. If you need the outline of coverage in Spanish, follow this link to see all plans in Spanish.
Oscar Gold
Oscar has grown in 2024. Now offering three Gold metal plans. The Oscar Gold Standard is typical of Gold plans; it has a low deductible and lower coinsurance and provides the best coverage of the plans Oscar offers. Gold plans come with a higher price tag. They are best suited for those with chronic medical conditions requiring frequent doctor’s visits or those who desire advanced medical care.
| Gold | Gold Elite | Gold Classic Standard |
| Deducible (Individual/Family) | $750/$1500 | $1500/$3000 |
| Coinsurance | 30% | 25% |
| Out-of-Pocket Max (Individual/Family) | $5500/$11,000 | $8700/$17,400 |
| Primary Care Visit | $25 | $30 |
| Virtual PCP Visits | $0 | $0 |
| Specialist Visit | $50 | $60 |
| Emergency Room | 30% after deductible | 25% after deductible |
| Urgent Care | $50 | $45 |
| Virtual Urgent Care | $0 | $0 |
| Inpatient Hospital | 30% after deductible | 25% after deductible |
| Outpatient Hospital | 30% after deductible | 25% after deductible |
| Prescription (Pharmacy) | $3/$25/$75/30% after ded.* | $15/$15/$30/$60/$250* |
*Prescriptions are Generics: Preferred and Non-Preferred; Brand:/Preferred, Non-Preferred, and Specialty
Oscar Dental and Vision:
Currently, Oscar does not offer Dental or Vision plans as stand-alone policies or add-ons. Although they are offering Affordable Care Act policies, they must offer these benefits to children as part of the 10 Essential Benefits. Review your policy’s outline of coverage for your specific 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 assists you with searching for doctors and facilities near you and gives you important information 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. Members pay rates with in-network providers until they reach their deductible.
–Member pays coinsurance 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 need 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.
- Mail order RX – Prescriptions delivered through CVS Mail Order or Capsule home delivery.
- Virtual Urgent Care – Benefit to ensure you will be taking the right meds the first time.
Oscar can help you find a pharmacy in your area through its website, including prescription mail delivery.
At CoverMile, we desire to assist you in finding the best health insurance in Texas that will fit you and your family’s needs We take the time to get to know your situation, 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.
