Ambetter Essential Care 5 + Vision + Adult Dental (2022) - Orange - IN

Ambetter Essential Care 5 + Vision + Adult Dental (2022) - Orange - IN

  43 InfoPreferred Score Good

specifications

  • Premium 403.41 Dollar(s)
  • Deductibles 8300 Dollar(s)
  • Out of Pocket Maximum 8700 Dollar(s)
  • Covered Benefits 32 out of 40

Key Features

$ 403.41
Premium
Very Good
$ 8300
Deductibles
Poor
$ 8700
Out of Pocket Maximum
Poor
32 / 40
Covered Benefits
Good

  • Overview

    Plan ID: 76179IN0130069
    Plan Type: EPO
    Metal Level: Bronze
    Covered Benefits: 32
    County: Orange
    FIPS County Code: 18117
    State: IN
    SM Rating: 43

  • Cost of Medical Sharing

    Premium: 403.41
    EHB Premium: 386.31
    EHB Percent of Total Premium: 95
    Deductibles: 8300
    Out of Pocket Maximum: 8700

  • Cost Sharing

    Adult Dental Care Details: 50%
    Child Dental Care Details: Benefit Not Covered
    Child Dental Check Up: Benefit Not Covered
    Adult Major Dental Care: 50%
    Child Major Dental Care: Benefit Not Covered
    Adult Routine Dental Services: No Charge
    Eye Glasses for Children: No Charge
    Adult Routine Eye Exam Details: No Charge
    Child Routine Eye Exam Details: No Charge
    Hearing Aids Details: Benefit Not Covered
    Bariatric Surgery: Benefit Not Covered
    Chemotherapy: 50% Coinsurance after deductible
    Chiropractic Care: $90
    Dialysis: 50% Coinsurance after deductible
    Durable Medical Equipment: 50% Coinsurance after deductible
    Emergency Room Services: 50% Coinsurance after deductible
    Emergency Transportation Ambulance: 50% Coinsurance after deductible
    Habilitation Services: 50% Coinsurance after deductible
    Imaging (CT, Pet, MRIS Scan): 50% Coinsurance after deductible
    Infertility Treatment: Benefit Not Covered
    Inpatient Hospital Services: 50% Coinsurance after deductible
    Inpatient Physician and Surgical Services: 50% Coinsurance after deductible
    Laboratory Outpatient and Professional Services: $50
    Mental Behavioral Health Inpatient Services: 50% Coinsurance after deductible
    Mental Behavioral Health Outpatient Services: $40
    Adult Orthodontia: Benefit Not Covered
    Child Orthodontia: Benefit Not Covered
    Outpatient Facility Fee: 50% Coinsurance after deductible
    Outpatient Rehabilitation Services: 50% Coinsurance after deductible
    Outpatient Surgery Services: 50% Coinsurance after deductible
    Preventive Care Screening Immunization: No Charge
    Primary Care Visit: $40
    Private Duty Nursing: 50% Coinsurance after deductible
    Skilled Nursing Facility: 50% Coinsurance after deductible
    Specialist Visit: $90
    XRays and Diagnostic Imaging: 50% Coinsurance after deductible

  • Prescription Drug Coverage

    List of Covered Drugs URL: https://ambetter.mhsindiana.com/resources/pharmacy-resources.html
    Generic Drugs: $27
    Non Preferred Brand Drugs: 50% Coinsurance after deductible
    Preferred Brand Drugs: 50% Coinsurance after deductible
    Specialty Drugs: 50% Coinsurance after deductible

  • Benefits

    Dental Benefits: 3
    Vision Benefits: 3
    Hearing Benefits: 0
    Other Benefits: 26
    Adult Dental Care: 1
    Child Dental Care:
    Adult Routine Eye Exam: 1
    Child Routine Eye Exam: 1
    Hearing Aids:
    National Network Available:
    Health Savings Account Eligibility:
    Disease Management Programs: Asthma, Diabetes, Heart Disease, Pregnancy

  • Plan Documents

    Provider Directory URL: https://ambetter.mhsindiana.com/findadoc
    Benefits Summary URL: https://api.centene.com/SBC/2022/76179IN0130069-01.pdf
    Brochure URL: https://www.ambetterhealth.com/content/dam/centene/ambetter-brochures/IN-2022.pdf

  • Policy Issuer Details

    Eligible Dependents: Self, Spouse, Child, Stepson or Stepdaughter, Grandson or Granddaughter, Brother or Sister, Life Partner, Nephew or Niece, Collateral Dependent, Ex-Spouse, Foster Child, Ward, Sponsored Dependent, Other Relationship, Other Relative
    Issuer: Ambetter from MHS
    Issuer ID: 76179
    Area: Rating Area 15

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