Ambetter Essential Care 5 (2021) + Vision + Adult Dental Plan Details for 2021- HealthPocket
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Ambetter Essential Care 5 (2021) + Vision + Adult Dental

$431.45/mo
View BrochureSummary of BenefitsProvider Directory

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Zip Code39503
Applicant6/27/1987 Male
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Benefits & Coverage

Insurance TypeACA (Obamacare)
Plan NameAmbetter Essential Care 5 (2021) + Vision + Adult Dental
Plan IDhhs-90714MS0030010
Plan Year2021
Insurance ProviderAmbetter
Metal LevelExpanded Bronze
Plan TypeHMO
Deductible$8,100
Out-of-Pocket Maximum$8,500
Plan Highlights

Costs for Medical Care

Primary Care Visit to Treat an Injury or Illness$40 Copay
Specialist Visit$90 Copay
Laboratory Outpatient and Professional Services$45 Copay
X-rays and Diagnostic Imaging50.00% Coinsurance after deductible
Diagnostic Imaging such as MRIs, CT, and PET scans50.00% Coinsurance after deductible
Deductible - Family$16200 per group
Out-of-Pocket Maximum - Family$17000 per group

Prescription drug coverage

Generic Drugs$30 Copay
Preferred Brand Drugs50.00% Coinsurance after deductible
Non-Preferred Brand Drugs50.00% Coinsurance after deductible
Specialty Drugs50.00% Coinsurance after deductible

Access to doctors and hospitals

Provider directory URLhttps://providersearch.ambetterhealth.com/
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 Services50.00% Coinsurance after deductible
Inpatient Hospital Services (e.g., Hospital Stay)50.00% Coinsurance after deductible
Inpatient Physician and Surgical Services50.00% Coinsurance after deductible
Emergency Transportation or Ambulance Service50.00% Coinsurance after deductible

Maternity

Prenatal and Postnatal Care$40 Copay
Delivery and all inpatient services for maternity care50.00% Coinsurance after deductible

Mental Health

Mental/Behavioral Health Outpatient Services$40 Copay
Mental/Behavioral Health Inpatient Services50.00% Coinsurance after deductible
Substance use disorder outpatient services$40 Copay
Substance use disorder inpatient services50.00% Coinsurance after deductible

Medical Management Programs

Does this plan offer disease managment programs?Asthma, Diabetes, Heart Disease, High Blood Pressure & High Cholesterol, Low Back Pain, 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 CareIncluded

Exclusions and Limitations

More Included BenefitsOther Practitioner Office Visit (Nurse, Physician Assistant)
Preventive Care/Screening/Immunization
Imaging (CT/PET Scans, MRIs)
Outpatient Surgery Physician/Surgical Services
Urgent Care Centers or Facilities
Inpatient Physician and Surgical Services
Home Health Care Services
Durable Medical Equipment
Routine Foot Care
Dental Anesthesia
Diabetes Care Management
Mental Health Other
Accidental Dental
Allergy Testing
Chemotherapy
Diabetes Education
Dialysis
Infusion Therapy
Laboratory Outpatient and Professional Services
Prosthetic Devices
Radiation
Reconstructive Surgery
Transplant
Well Baby Visits and Care
Off Label Prescription Drugs
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 BenefitsSkilled Nursing Facility
Outpatient Rehabilitation Services
Habilitation Services
Hospice Services
Chiropractic Care
Dental Care - Adult
Rehabilitative Occupational and Rehabilitative Physical Therapy
Rehabilitative Speech Therapy
Treatment for Temporomandibular Joint Disorders
Cardiac Rehabilitation
Inpatient Rehabilitation
Eyeglasses for Adults
More Excluded BenefitsAcupuncture
Bariatric Surgery
Cosmetic Surgery
Hearing Aids
Infertility Treatment
Long Term Care
Private-Duty Nursing
Weight Loss Programs
Dental Check-Up for Children
Abortion for Which Public Funding is Prohibited
Nutritional Counseling
Long-Term/Custodial Nursing Home Care
PremiumPlan NameDeductible
from $408Cigna Connect 8200 ($0 Telehealth)$8,200.00Select
from $414Ambetter Essential Care 5 (2021)$8,100.00Select
from $439Cigna Connect 8100 ($0 Telehealth)$8,100.00Select
from $443Ambetter Balanced Care 32 with Walgreens$8,100.00Select
from $462Ambetter Balanced Care 32 with Walgreens + Vision + Adult Dental$8,100.00Select
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  • Phone Number
    (228) 832-9933
  • Office Locations
    12080 New Orleans Ave N
    Gulfport, MS 39503
12080 New Orleans Ave N Gulfport MS, 39503

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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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