What Oscar Health Insurance Is

Oscar is a health insurance company that sells plans through the Affordable Care Act (ACA) marketplace in most U.S. states. It offers health maintenance organization (HMO) and preferred provider organization (PPO) plans, meaning you choose doctors from Oscar's network and pay less when you use in-network providers. Oscar does not sell insurance outside the ACA marketplace — you cannot buy directly from the company without going through Healthcare.gov or your state's marketplace.

Oscar was founded in 2013 and operates in roughly 20 states, though the number changes year to year. The company focuses on individual and family plans rather than employer coverage. If you are shopping for marketplace insurance during open enrollment (usually November through January) or after a may have access to life event, Oscar plans appear alongside other insurers' offerings on your state's marketplace.

Oscar plans cover the same 10 essential health benefits that all ACA plans must include: preventive care, hospitalization, emergency services, prescription drugs, mental health services, maternity care, pediatric dental and vision, and rehabilitation services. The specific coverage details, deductibles, and copayments vary by plan tier and state.

Key Takeaways

  • Oscar sells HMO and PPO plans only through the ACA marketplace during open enrollment or after a may have access to event; you cannot buy directly from Oscar.
  • All Oscar plans cover the same 10 essential health benefits, but deductibles, copayments, and out-of-pocket maximums differ by plan and state.
  • Oscar uses a network of doctors and hospitals; using in-network providers costs less than using out-of-network ones, especially in HMO plans.
  • You may owe no premium if your income qualifies you for a tax credit, and Oscar's website shows the final price after credits are applied.
  • Oscar plans renew each year on January 1, and you must actively choose a new plan during open enrollment or your coverage may end.

How Oscar's Network and Provider Access Works

Oscar plans require you to choose a primary care doctor from the network. In an HMO plan, you must see your primary care doctor first for most care, and that doctor refers you to specialists. If you see a specialist without a referral, you typically pay the full cost yourself. In a PPO plan, you can see specialists without a referral, but you pay more out of pocket than you would in an HMO.

Oscar publishes its provider network on its website, organized by state and plan. You can search for doctors, hospitals, and urgent care centers to see whether your current providers are in-network. Network composition changes, so a provider who was in-network last year may not be this year. If your doctor leaves Oscar's network, Oscar is required to notify you, and you have the right to request a continuity-of-care arrangement so you can finish treatment with that doctor at in-network rates.

Out-of-network care is covered but costs significantly more. You pay a higher copayment or coinsurance percentage, and the deductible may not explore. Emergency services are covered at in-network rates even if you go to an out-of-network hospital, but non-emergency urgent care at an out-of-network facility is not.

Deductibles, Copayments, and Out-of-Pocket Limits

Oscar offers plans at four metal tiers: Bronze, Silver, Gold, and Platinum. Bronze plans have the lowest monthly premium but the highest deductible and out-of-pocket costs. Platinum plans have the highest monthly premium but the lowest deductible and out-of-pocket costs. Silver and Gold fall in between.

A deductible is the amount you pay out of pocket before Oscar's insurance kicks in. Once you meet your deductible, you typically pay a copayment (a fixed dollar amount per visit) or coinsurance (a percentage of the cost). Preventive care — annual checkups, screenings, vaccines — is covered with no copayment or deductible, regardless of plan tier.

An out-of-pocket maximum is the most you will pay in a year for in-network care. Once you reach this limit, Oscar covers 100 percent of in-network care for the rest of the year. Out-of-pocket maximums vary by plan and state but are set by federal law. For 2024, the federal maximum for individual coverage is $9,200 and for family coverage is $18,400, though Oscar's actual limits may be lower.

Prescription drug coverage is included in all Oscar plans. You pay a copayment or coinsurance for each prescription, and the amount depends on the drug's tier on Oscar's formulary (the list of covered medications). Some drugs require prior authorization, meaning Oscar must approve them before the pharmacy will fill them.

Tax Credits and How They Affect Your Premium

If your household income is between 100 and 400 percent of the federal poverty level, you may receive an Advanced Premium Tax Credit (APTC), which reduces your monthly premium. Oscar's marketplace page shows the price after credits are applied, so you see the actual amount you will pay each month. You do not explore for the credit through Oscar; you report your income on the marketplace process, and the marketplace calculates your credit.

Tax credits are based on your estimated income for the year. If your income changes during the year — you lose a job, get a raise, or have a major life event — you can report the change to the marketplace and your credit amount will adjust. If you underestimate your income and receive more credit than you should have, you will owe the difference back when you file taxes the following year. If you overestimate your income, you may get a refund.

You can also receive cost-sharing reductions (CSRs) if you choose a Silver plan and your income qualifies. CSRs lower your deductible, copayments, and out-of-pocket maximum, making the plan more affordable. CSRs are only available on Silver plans, not on Bronze, Gold, or Platinum plans.

How to Enroll in an Oscar Plan

You enroll in Oscar plans through Healthcare.gov (the federal marketplace) or your state's marketplace, not through Oscar directly. Open enrollment runs from November 1 through January 15 each year. If you miss open enrollment, you can still enroll if you have a may have access to life event: losing health coverage, getting married, having a baby, moving to a new state, or experiencing a significant change in income.

During enrollment, you enter your household size, income, and current coverage status. The marketplace shows you all available plans, including Oscar's offerings, along with the monthly premium after any tax credits. You compare plans by deductible, copayment amounts, and provider network. Once you choose an Oscar plan, you complete the enrollment on the marketplace, not with Oscar.

After you enroll, Oscar sends you a member ID card and welcome packet with information about your plan, network, and how to access care. Your coverage begins on the first day of the month after you enroll, unless you enroll between December 1 and 15, in which case coverage begins January 1. You can view your plan details and find providers on Oscar's member portal.

What Happens When Your Plan Renews Each Year

Oscar plans renew on January 1 each year. Before December, the marketplace sends you a notice showing your current plan and its premium for the next year. Oscar's plans may change — the company may raise or lower premiums, change the deductible or copayments, or adjust the provider network. You are not automatically re-enrolled; you must actively choose a plan during open enrollment.

If you do nothing and open enrollment passes, your coverage ends on December 31. You will have no health insurance starting January 1 unless you enroll in a new plan. The marketplace does not automatically renew you into the same plan, even if you were happy with it. You must log into the marketplace, review your options, and select a plan between November 1 and January 15.

If your income changes, you should update it on the marketplace before open enrollment ends. A change in income can affect your tax credit and may make a different plan more affordable. You can also switch to a different Oscar plan or a plan from another insurer during open enrollment without penalty.

Common Reasons Oscar Plans May Not Be Available to You

Oscar does not operate in all states. As of 2024, Oscar sells plans in roughly 20 states, but this number changes annually. If Oscar does not serve your state, you will not see Oscar plans on your marketplace. You can check whether Oscar operates in your state by visiting Oscar's website or searching the marketplace for your state and ZIP code.

Even if Oscar operates in your state, not all plans may be available in your ZIP code. Oscar's service area within a state is sometimes limited to certain counties or regions. When you enter your ZIP code on the marketplace, only plans available in your area appear.

If you have employer-sponsored health insurance, you generally cannot buy an ACA marketplace plan, including Oscar's, unless your employer's plan is deemed unaffordable (the employee premium exceeds a certain percentage of household income). If you are on Medicare, you cannot enroll in an ACA marketplace plan at all.

Frequently Asked Questions

Can I switch from Oscar to another insurance company mid-year?

No, you cannot switch plans outside of open enrollment unless you have a may have access to life event. may have access to events include losing coverage, getting married, having a baby, moving to a new state, or experiencing a significant income change. If you have a may have access to event, you have 60 days to enroll in a new plan.

What happens if my doctor leaves Oscar's network?

Oscar must notify you when a doctor leaves the network. You have the right to request continuity of care, which allows you to continue seeing that doctor at in-network rates for a limited time, usually 90 days. Contact Oscar's member services to request this arrangement.

Do Oscar plans cover telehealth visits?

Yes, Oscar plans cover telehealth visits with in-network providers. You typically pay the same copayment as you would for an in-person visit. Check your plan details or call Oscar's member services to confirm whether your specific plan includes telehealth and which providers are available.

What if I cannot afford the monthly premium even after tax credits?

If no plan is affordable, you may be exempt from the individual mandate penalty. You can request a hardship exemption on the marketplace. You can also choose a Bronze plan, which has the lowest monthly premium, though it has higher out-of-pocket costs when you use care.

How do I contact Oscar if I have a billing question or need to file a claim?

Oscar's member services phone number is on your member ID card and in your welcome materials. You can also log into Oscar's member portal online to view claims, request prior authorization, or message customer service. Oscar typically responds to online messages within one business day.