Benefits

Health insurance plans cover a huge range of medical services and drugs. It's important to make sure when you get care that you're receiving services or medications that are covered benefits under your plan so that you don't end up paying more than you should. Depending on the services you receive and the details of your plan, your plan might pay the entire bill, a portion of the bill, or none of it.

If you're responsible for a bill, you’ll get the benefit of your insurer's negotiated rate (opens in new tab), which can be 10%-60% below full price. As long as you see an in-network provider (opens in new tab) for a covered benefit, your payment will count toward your deductible and/or maximum out-of-pocket (opens in new tab), limiting your financial exposure to big medical bills. Which benefits are included and how much you’ll spend depends on how your plan covers the services you received.

What medical benefits are covered?

The Affordable Care Act (opens in new tab) requires every individual health plan to cover a variety of health care procedures and services known as essential health benefits. To find out if a specific service is covered, it’s a good idea to look online or call your Oscar concierge for more detailed benefits information.

What services might not be covered benefits?

While most HMO and EPO (opens in new tab) health plans (like Oscar) pay for most medical services you need, they don’t pay for every procedure out there. There are a few common reasons a service may not be covered:

• If a procedure is “elective.” For most insurers, a procedure has to be considered “medically necessary” to be covered. Elective procedures (such as cosmetic surgery or in vitro fertilization) are planned in advance and usually don’t involve a medical emergency. Some plans do cover some elective surgeries like cataract surgery or ear tubes, while some don’t. Be sure to read through your benefits to find out what’s included in your plan.
• If you get care or a service from an “out-of-network” provider. Insurers negotiate rates and contracts with doctors, hospitals, and other health care providers. These are known as in-network providers. Every health care provider not on this list is considered "out-of-network". (opens in new tab) If you get care from someone who is out-of-network, it is not covered by your insurance (except in some emergencies).
• If it’s related to routine dental or vision care. Getting your teeth cleaned or a glasses prescription isn’t typically covered by your health insurance, so you may want to get separate insurance for those services. You can shop for those plans through the marketplace. Please remember that Oscar does not offer dental insurance or vision insurance.