Ambetter Balanced Care 203 (2021) + Vision + Adult Dental Plan Details for 2021- HealthPocket
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Ambetter Balanced Care 203 (2021) + Vision + Adult Dental

$300.16/mo
View BrochureSummary of BenefitsProvider Directory

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Zip Code60629
Applicant9/18/1986 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAmbetter Balanced Care 203 (2021) + Vision + Adult Dental
Plan IDhhs-27833IL0170004
Plan Year2021
Insurance ProviderAmbetter of Illinois
Metal LevelSilver
Plan TypeHMO
Deductible$6,450
Out-of-Pocket Maximum$8,200
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$15 Copay
Specialist Visit35.00% Coinsurance after deductible
Laboratory Outpatient and Professional Services$35 Copay
X-rays and Diagnostic Imaging35.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans35.00% Coinsurance after deductible
Deductible - Family$12900 per group
Out-of-Pocket Maximum - Family$16400 per group

Prescription drug coverage

Generic Drugs$35 Copay
Preferred Brand Drugs$75 Copay
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://www.ambetterofillinois.com/findadoc
Does this plan have access to a national provider network?No
Is a referral required to see a Specialist?Not Covered
Does this plan cover services outside plan service area?Not Covered
Does this plan cover services outside the country?Not Covered

Hospital services

Emergency Room Services35.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)35.00% Coinsurance after deductible
Inpatient Physician and Surgical Services35.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service35.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$15 Copay
Delivery and all inpatient services for maternity care35.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services25.00% Coinsurance
Mental/Behavioral Health Inpatient Services35.00% Coinsurance after deductible
Substance use disorder outpatient services25.00% Coinsurance
Substance use disorder inpatient services35.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, Pregnancy
Does this plan offer a wellness program?Not Covered

Vision Coverage

Routine Eye Exam for ChildrenIncluded
Eye Glasses for ChildrenIncluded
Routine Eye Exam for AdultsIncluded

Child Dental Coverage

Child Dental Coverage - Routine Dental CareNot Covered
Child Dental Coverage - Basic Dental CareNot Covered
Child Dental Coverage - OrthodontiaNot Covered
Child Dental Coverage - Major Dental CareNot Covered

Adult Dental Coverage

Adult Dental Coverage - Routine Dental CareIncluded
Adult Dental Coverage - Basic Dental CareIncluded
Adult Dental Coverage - OrthodontiaNot Covered
Adult Dental Coverage - Major Dental CareNot Covered

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Skilled Nursing Facility
Bariatric Surgery
Cosmetic Surgery
Infertility Treatment
Private-Duty Nursing
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Outpatient Rehabilitation Services
Habilitation Services
Durable Medical Equipment
Hospice Services
Routine Foot Care
Dental Anesthesia
Inherited Metabolic Disorder - PKU
Abortion for Which Public Funding is Prohibited
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Nutritional Counseling
Prosthetic Devices
Radiation
Reconstructive Surgery
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Transplant
Treatment for Temporomandibular Joint Disorders
Well Baby Visits and Care
Autism Spectrum Disorders
Bones/Joints
Breast Implant Removal
Cardiac Rehabilitation
Multiple Sclerosis
Organ Transplants
Prescription Drugs Other
Outpatient Facility Fee (e.g., Ambulatory Surgery Center)
Mental/Behavioral Health Emergency Room
Mental/Behavioral Health Emergency Transportation/Ambulance
Mental/Behavioral Health ER Physician Fee
Mental/Behavioral Health Outpatient Other Services
Mental/Behavioral Health Urgent Care
Substance Use Disorder Emergency Room
Substance Use Disorder Emergency Transportation/Ambulance
Substance Use Disorder ER Physician Fee
Substance Use Disorder Outpatient Other Services
Substance Use Disorder Urgent Care
Telehealth and Virtual Care
More Limited BenefitsHearing Aids
Chiropractic Care
Eyeglasses for Adults
Naprapathic service
More Excluded BenefitsAcupuncture
Weight Loss Programs
Dental Check-Up for Children
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $283Ambetter Balanced Care 203 (2021)$6,450.00Select
from $334Ambetter Balanced Care 12 (2021)$6,500.00Select
from $335MercyCare HMO Bronze Option A$6,500.00Select
from $353Ambetter Balanced Care 12 (2021) + Vision + Adult Dental$6,500.00Select
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  • Phone Number
    (773) 884-1662
  • Office Locations
    2701 W 68th St
    Chicago, IL 60629
2701 W 68th St Chicago IL, 60629

  • What Is the Silver Plan?

    ObamaCare’s Silver Plan is a type of Metal Plan on the Health Insurance Marketplace. Silver Plans qualify for both Tax Credits and Cost Sharing subsidies.Silver Plans have lower out-of-pocket costs than Bronze Plans but higher out- of-pocket costs than both Gold and Platinum Plans. All Silver Plans share the same minimum health benefits, but the way they charge out-of-pocket costs can differ significantly.

  • How are Silver Plans different than other Obamacare health plans?

    The fundamental difference among the new Obamacare health plans is the percentage of covered medical costs paid by the health plan. The Silver Plan pays 70% of covered medical costs for a typical enrollee. Silver Plans are also the only metal plans which offer cost-sharing reduction (CSR) versions to consumers that require financial assistance for out-of-pocket costs.

  • How much does a Silver Plan cost?

    The monthly premium for a Silver Plan depends on the insurer from whom you purchase the plan, the number of people to be insured by the plan, your age, whether you smoke, and the region in which you live. You can use HealthPocket’s comparison tool to compare Silver Plan premiums in your area.

  • When Can I Enroll in a Silver Plan?

    The Open Enrollment period for the 2018 Affordable Care Act health plans begins November 1, 2017 and ends December 15, 2017. See our Open Enrollment article for more information.

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HealthPocket.com is a free information source. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. While on our site, if you click on a plan or link, you may be directed to one of our partners who offers health insurance products. HealthPocket, Inc. is part of the Benefytt Technologies, Inc. family of companies.

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